r^N 


E!li;''V'))^''''';r''i'''f- 

w?fe'' '■■■'' 


Columbia  5BnitJers^itp 
intlieCttptjflrtogork 

College  of  ^Ijpsiiciang  anb  burgeons! 
ILitirarp 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/pathologicalsurg02brod 


PATHOLOGICAL        /^ 
SURGICAL   OBSERVATIONS     / f'i^i 


ON 


a©iiii©ii 


OF 


THE    JOINTS. 


By  B.  C.  BRODIE,  F.  R.  S. 

ASSISTANT  SURGEON  TO  ST.  GEORGe's  HOSPITAL, 

AND 

LECTURER  ON  THE  THEORY  AND  PRACTICE 

OF    SURGERY. 


ILLUSTRATED  BY  COLOURED  ENGRAVINGS. 
PHILADELPHIA: 

PUBLISHED  BY  BENJAMIN  WARNER,  AND  SOLD  ALSO  AT  HIS 
STORED  IN  RICHMOND,  VA.    AND  LOUISVILLE,  KEN. 
AKD  BY 

W.  r.  BASON,  CHARLESTON,  S.  C. 


1821. 

fBAKKISH,  PRINTER. 


':> 


\ 


t^V     H         \    -\ 


TO 

SIR  EVERARD  HOME,  BART. 

V.P.R.S. 

SENIOR  SURGEON  TO  ST.  GEORGE's  HOSPITAL, 
8cc.  &C.  &C. 


Dear  Sir, 

In  dedicating  to  you  the  follow- 
ing observations,  I  am  anxious  to  avail 
myself  of  the  first  opportunity,  which  has 
occurred,  of  publicly  expressing  my  grati- 
titude  far  the  numerous  favours,  which  I 
have  received  from  you,  from  the  time  of 
my  first  commencing  my  professional 
pursuits;  and  of  acknowledging  the  obli- 
gations, which  I  owe,  to  your  example,  to 
your  instructions,  and  to  your  fiiendl}^ 
assistance,  on  many  and  various  occa- 
sions. 


IV 

Independently  of  these  private  consi- 
derations, I  should  have  been  desirous 
of  prefixing  your  name  to  this  volume, 
as  a  mark  of  my  respect  for  one,  whose 
talents  and  unwearied  exertions  have  so 
essentially  contributed  to  the  advance- 
ment of  surgery,  and  of  those  interesting 
branches  of  philosophy,  which  are  con- 
nected with  it. 

I  remain,  Dear  Sir, 
Your  faithful  friend  and  servant, 

B.  C.  BRODIE. 

Sackville  Street^ 
October  19,  18(8, 


CONTENTS. 


Introduction  _        >         _        -        Page     1 

CHAP.  I. 

ON  INFLAMMATION  OF  THE  SYNOVIAL  MEMBRANES 
OF  JOINTS. 

Sect.  I.  Pathological  Observations  -  -  6 
Sect.  II.     On  the  Causes  and  Symptoms  of  this 

^                     Disease             -          -         -         -  18 

Sect.  III.    On  the  Treatment         -         -         -  30 

Sect.  IV.     Cases           -         -         -         -         -  39 

CHAP.  II. 

ON  ULCERATION  OF  THE  SYNOVIAL   MEMBRANE,       64 

CHAP.  III. 

ON  CASES,  IN  WHICH  THE  SYNOVIAL  MEMBRANE  HAS 
UNDERGONE  A  MORBID  CHANGE  OF  STRUCTURE. 

Sect.  I.  Pathological  Observations  -  -  68 
Sect.  II.  On  the  Symptoms  of  this  Disease  -  93 
Sect.  III.  On  the  Treatment  -         -         -     98 


vi  CONl'ENTS. 


CHAP.  IV. 

ON  THE  ULCERATION  OF  THE  CARTILAGES  OF 
JOINTS. 

Sect.  I.  Pathological  Observations  -  Page  101 
Sect.  II.  On  the  Symptoms  of  this  Disease  138 
Sect.  III.  On  the  Treatment  -  .  .  i63 
Sect.  IV.     Cases 192 


CHAP.  V. 

ON  A  SCROPHULOUS  DISEASE  OF  THE  JOINTS  HAVING 
ITS  ORIGIN  IN  THE  CANCELLOUS  STRUCTURE  OF 
THE  BONES. 

Sect.  I.     Pathological  Observations       -        -  209 

Sect.  II.     On  the  Symptoms  of  this  Disease  229 

Sect.  III.     On  the  Treatment         -         -       -  239 

Sect.  IV.     Cases         .         »         -         .         -  250 


CHAP.  VI. 

ON  CARIES   OF  THE    SPINE. 

Sect.  I.     Pathological  Observations       -        -     259 
Sect.  II.     On  the  Symptoms  of  Caries  of  the 

Spine  -         _         .  -     276 

Sect.  III.     On  the  Treatment  -  -     287 

CHAP.  VII. 

ON  SOME  OTHER  DISEASES   OF  THE  JOINTS.  295 


CONTENTS.  vii 

CHAP.  VIII. 

ON  INFLAMMATION  OF  THE   BURS^E  MUCOSAE. 

Sect.  I.     History  and  Symptoms  of  this  Dis- 
ease          -          -         -             Page  305 
Sect.  II.     On  the  Treatment         .         -         -  312 
Sect.  III.     Cases            ..        .          >            -  318 


Explanation  of  the  Plates  -  -         -    325 


INTRODUCTION. 


The  following  pages  contain  a  series  of 
obseiTations,  which  were  begun  several 
years  ago,  and  which  have  been  con 
tinned,  not  without  considerable  labour, 
up  to  the  present  period.  They  relate  t(i 
a  class  of  diseases,  which  have  strong 
claims  on  the  attention  of  the  surgeon; 
since  they  are  of  very  frequent  occur- 
rence; are  a  source  of  serious  anxiety  to 
the  patients;  and,  for  the  most  part,  if  ne- 
glected, proceed  to  an  unfavorable  terr 
mination.  There  are  other  circuii>§t^nces 
also,  which  seemed  to  render  tll^  morbid 
affections  of  the  joints  a  fit  subject  of  in- 
vestigation. They  have  scarcely  met  with 
the  attention,  whicl^  they  merit  from 
former  pathologists^  The  terms,  white 
swellings,   scrophulous  joints,   §c.   have 


;    (  2  ) 

])een  used  without  any  well-defined  mean- 
ing, and  almost  indiscriminately;  so  that 
the  same  name  has  been  frequently 
applied  to  different  diseases,  and  the 
same  disease  lias  been  distinguished  by 
different  appellations.  Confusion  with 
respect  to  diagnosis  always  gives  rise 
to  a  corresponding  confusion  with  re- 
spect to  the  employment  of  remedies; 
and  hence  I  was  induced  to  hope,  that, 
if  it  were  possible  to  improve  our  pa- 
tliological  knowledge  of  the  diseases  to 
which  I  have  alluded,  this  might  lead, 
not  indeed  to  the  discovery  of  new 
methods  of  treatment,  but  to  a  more  ju- 
dicious and  scientific  application  of  those 
which  are  already  known,  and  a  conse- 
quent improvement  of  chirurgical  prac- 
tice. 

The  joints,  like  the  other  animal  or- 
gans, are  not  of  a  simple  and  uniform,  but 
of  a  various  and  complicated  structure. 
Although  in  the  advanced  stages,  the  dis- 
eases, to  which  they  are  liable,  extend  to 


(  ^o 

all  tlie  dissimilar  parts  of  which  they  arc 
composed,  it  is  to  be  presumed  that  such 
is  not  the  c^se  in  the  beginning.  We 
cannot  doubt,  that  here,  as  elsewhere, 'the 
morbid  actions  commence,  sometimes  in 
one,  and  sometimes  in  another  texture; 
and  that  they  differ  in  their  nature,  and 
are  variously  modified,  and  of  course  re- 
quire to  be  differently  treated,  according 
to  the  mechanical  organization,  and  the 
vital  properties  of  the  part,  in  which  they 
originate. 

It  was  under  the  influence  of  these 
impressions  that  I  endeavoured  to  pursue 
ray  enquiries  into  the  subject  of  the  pre- 
sent treatise.  Believing,  that  nothing  has 
contributed  in  a  gTcater  degree  towards 
the  modern  improvements  'in  surgery, 
than  the  practice  of  investigating  by  dis- 
section the  changes  of  anatomical  struc- 
ture, which  disease  produces,  I  availed 
myself  of  every  opportunity  which  oc- 
curred of  making  such  examinations.  In 
particular,  I  was  anxious  to  do  this,  where 


(      4      ) 

the  rtiorbid  changes  were  still  in  an  early 
stage,  and  where  I  had  the  opportunity  of 
jQOting  the  symptoms  by  which  the  in- 
cipient  disease    was  indicated;   and   the 
knowledge  which  was  thus   acquired  be- 
came the  basis  of  my  future  observations. 
In  laying  the  results  before  the  public,  I 
cannot  be  otherwise  than  conscious,  that 
these  researches  are  still  imperfect.    But 
I  feel  assured,  at  the   same  time,  that 
those  who  are  engaged  in  the  study  of 
pathology,  will  make  due  allowance  for 
the  difficulties,  which  belong  to  this  most 
complicated  of  all  the  sciences,  and  will 
not  be  disposed  to  criticise  my  labours 
severely,  because  they  find,  that  there  is 
still  an  ample  space  left  for  those,  who 
may    be    willing  to    engage    in    similar 
enquiries. 

Some  of  my  readers  will  recognize  in 
the  present  work  the  substance  of  some 
papers,  which  were  published  in  the 
fourth  and  two  subsequent  volumes  of 
the  Medico-Chirurgical  Transactions;  but 


(      5       ) 

they  Mill  also  find  a,  considerable  propor- 
tion of  new  matter.  I  have  met  with  no 
reasons  for  altering  my  former  arrang<^- 
ment  of  those  affections  of  the  joints 
which  are  of  most  frequent  occurrence. 
Indeed  it  has  been  to  me  a  source  of 
much  satisfaction,  that  all  my  subsequent 
observations,  founded  on  numerous  addi- 
tional cases  and  dissections,  have  tended 
to  confirm  the  accuracy  of  those  patho- 
logical views,  which  I  was  led  to  adopt 
several  years  ago,  and  which  1  ventured 
to  bring  forward  in  the  first  of  those  pa* 
pers,  to  which  I  have  alluded. 


CHAP.  I. 

ON  INFLAMMATION  OF  THE  SYNOVIAL  .MEM- 
BRANES OF  JOINTS. 


Sect.  I. 

Fatlwlogical  Observations. 

The  soft  parts,  which,  added  to  the  bones 
and  cartilages,  constitute  the  structure  of 
the  joints,  are,  the  synovial  membranes  hy 
which  the  lubricating  fluid  is  secreted; 
the  ligaments,  by  which  the  bones  are 
connected  to  each  other;  and  the  fatty 
substance,  which  occupies  what  in  cer- 
tain positions  would  otherwise  be  empty 
spaces.  It  is  to  be  supposed,  that  the 
adipose  membrane  belonging  to  the  joints 
may  be  inflamed;  that  it  may  be  the  seat 
of  abscesses  and  tumours,  as  well  as  that 
which  is  situated  beneath  the  skin  or  in 
the  interstices  of  the  muscles;  and  the 


(     7     ) 

Kgaments  cannot  be  regarded  as  more 
exempt  from  disease  tlian  the  fibrous 
membranes,  which  they  very  nearly  re- 
semble in  their  texture.  It  is  not 
improbable  that  the  pains  and  slight 
tumefactions  of  the  joints,  which  occa- 
sionally take  place  in  syphilitic  affections, 
may  depend  on  some  diseased  action  of 
the  ligaments;  and  there  can  be  little 
doubt  that  the  long  continued  symptoms, 
which  sometimes  follow  a  severe  sprain, 
depend  on  these  same  parts  being  in  a 
state  of  slow  inflammation,  in  conse- 
quence of  some  of  their  fibres  being  rup- 
tured, or  over=stretched.  I  cannot  say 
that  I  have  never  seen  a  case,  where  dis- 
ease, independently  of  these  causes,  has 
originated  in  the  ligaments;  but  I  cer- 
tainly have  never  met  with  a  case,  where 
it  has  been  proved  to  have  done  so,  by  dis- 
section; and  it  may  be  safely  asserted, 
that  this  is  a  rare  occurrence,  and  not 
what  happens  in  the  ordinary  diseases  to 
which  the  joints  are  liable. 


(      8      ) 

On  the  other  hand,  no  part  of  the  body 
is  much  more  frquently  diseased  than  the 
synovial  membranes.  This  is  what  their 
anatomical  structure  and  functions  might 
lead  us  to  expect,  since  we  find  that 
living  organs  are  more  subject  to  have 
their  natural  functions  deranged,  in  pro- 
portion as  they  are  more  vascular,  and  as 
they  are  employed  in  a  greater  degree  in 
the  process  of  secretion. 

The  synovial  membranes  of  the  joints 
have  not  been  well  described  by  the  ma- 
jority of  the  old,  nor  even  of  modern 
anatomists.  A  sufficiently  accurate  ac- 
count of  it  has  been  published  by  Dr.  W. 
Hunter,  in  a  communication  to  the  Royal 
Society  on  the  structure  of  cartilage,  pub- 
lished in  the  forty-second  volume  of  the 
Philosophical  Transactions,  and  since  then 
h\  M.  Bichat,  in  his  Traite  des  Mem- 
hranes;  and  to  these  authors  I  may  refer 
those  of  my  resulers,  who  wish  to  see  its 
iinatomy  more  fully  explained.  At  pre^ 
.4;ent  it  is  sufficient  for  me  to  observe,  that 


(      9      ) 

its   office  is  to  secrete  the  synovia,  by 
wliich  tlie  joints  are  lubricated;  that  it 
lines  the  ligaments,  by  which  the  bones 
are  held  together;  covers  the  bones  them- 
selves for  a  small  extent,  taking  the  place 
of  the  periosteum;  and  that  from  thence 
it  passes  over  the  cartilaginous  surfaces, 
and  the  inter-articular  fat.     Where  it  ad- 
heres to  the  bones  and  soft  parts,  it  very 
much  resembles  the  peritonaeum  in  its 
structure,  and  possesses  considerable  vas- 
cularity; but  where  it  is  reflected  over  the 
cartilages  it  is  thin,  and  readily  torn;— 
its  existence,  however,  even  here,  may  be 
always  distinctly  demonstrated  by  a  care- 
ful dissection.     The  synovial  membrane 
of  a  joint  forms  a  bag,  having  no  external 
opening;  in  this  respect  resembling  the 
peritonaeum,  the  pleura,  and  the  pericar- 
dium; which  it  also  resembles  in  its  func- 
tions; and  to  which  it  bears  some  analogy 
in  its  diseases. 

Cases  occasionally  (but  not  often)  occur 
in  which  a  joint  is  swollen  from  a  pre* 

3 


(    io    ) 

ternatural  quantity  of  fluid  collected  in 
its  cavity,  without  pain  or  inflammation* 
This  may  be  supposed  to  arise,  either,  from 
a  diminished  action  of  the  absorbents,  or 
an  increased  action  of  the  secreting  ves- 
sels. The  disease  may  be  compared  to 
the  dropsy  of  the  peritonseum,  or  pleura; 
or  more  properly,  to  the  hydrocele;  and 
it  has  been  not  improperly  designated  by 
the  terms,  "  Hydarthrus"  and  "  Hydrops 
articuli." 

It  more  frequently  happens  that  there 
is  swelling  from  fluid  in  a  joint  with  in- 
flammation and  pain.  Here  we  may  pre- 
sume that  the  disease  consists  in  an 
inflammation  of  the  synovial  membrane, 
with  a  consequent  increase  of  the  secre- 
tion from  its  surface;  and  this  is  con- 
firmed by  the  appearances  observed  in 
those  cases,  in  which  there  is  an  oppor- 
tunity of  examining  the  affected  parts 
after  death. 

In  many  instances,  while  there  is  still 
pain  and  inflammation  in  the  joint,  the 


(  11  ) 

iliiid  is  felt  indistinctly,  as  if  a  consider- 
able mass  of  soft  substance  lay  over  it. 
Often,  when  the  inflammation  has  subsi- 
ded, and  the  fluid  is  no  longer  to  be  felt, 
the  joint  remains  swollen  and  stiff;  pain- 
ful, when  bent  or  extended  beyond  a  cer- 
tain point,  and  liable  to  a  return  of  inflam- 
mation from  slight  causes.  The  appear- 
ances observed  in  the  following  cases,  in 
which  there  was  an  opportunity  of  ex- 
amining the  effects  which  the  disease  had 
produced,  seem  to  throw  light  on  this  sub- 
ject. 

CASE  I. 

A  middle-aged  man  was  admitted 
into  St.  George's  Hospital  in  September, 
1810,  on  account  of  a  disease  in  one 
knee.  The  joint  was  swollen  and  pain- 
ful, with  slight  stiffness,  and  with  fluid  in 
its  cavity.  The  swelling  extended  some 
way  up  the  anterior  part  of  the  thigh, 
behind  the  lower  portion  of  the  extensor 


(      12      ) 

rjiuscles.  It  subsided  under  the  use  of 
blisters  and  liniments.  Two  months 
after  his  admission  into  the  hospital, 
lie  was  seized  with  a  fever,  apparently 
unconnected  with  the  disease  in  the 
knee,  of  which  he  died.  On  examining 
the  effected  joint,  the  synovial  membrane 
was  found  much  diseased,  and  more  ca- 
pacious than  natural,  extending  up  the 
anterior  surface  of  the  femur  at  least 
an  inch  and  a  half  higher  than  usual. 
Throu«:hout  the  whole  of  its  internal  sur- 
face,  except  where  it  covered  the  car- 
tilages, the  membrane  was  of  a  dark  red 
colour;  the  vessels  being  as  numerous, 
and  as  much  distended  with  blood,  as 
those  of  the  tunica  conjunctiva  of  the 
eye  in  a  violent  ophthalmia.  At  the 
upper  and  anterior  part  of  the  joint,  a 
thin  flake  of  coagulable  lymph  was  effused 
from  the  inner  surface  of  the  synovial 
membrane,  of  the  size  of  a  half-crown 
piece.  There  was  no  other  appearance 
of  disease,  except  that  at  the  edge  of  one 


(  1^  ) 

or  the   condyles  of  the   femur   the   car 
tilage   adhered  to   the  hone  less  firmly 
than  usual. 


CASE  II. 

A.  B.,  a  young  man,  in  the  spring  of 
the  year  1808,  in  consequence  (as  he  sup- 
posed) of  exposure  to  damp  and  cold,  be- 
came affected  with  a  painful  swelling  of 
one  of  his  knees.  Under  the  treatment 
employed  by  the  practitioner  whom  he 
consulted,  the  pain  and  swelling  in  great 
measure,  but  not  entirely,  subsided.  Three 
months  after  the  disease  first  took  place, 
he  was  admitted  into  St.  Oeorge's  Hospi- 
tal. At  this  time  the  knee  was  swollen, 
painful,  and  tender.  The  swelling  had 
the  form  of  the  articulating  ends  of  the 
bones.  The  leg  was  confined  to  nearly 
the  straight  position,  and  admitted  of 
very  little  motion  on  the  tliigh.  His 
general  health  was  unaffected. 


(  *^  ) 

Blood  Mas  taken  from  the  kuee  by  cup- 
ping; and  afterwards  it  was  rubbed  daily 
with  mercurial  ointment  and  camphor. 
The  pain  and  inflammation  subsided:  and 
the  swelling  and  stiffness  were  in  some 
measure  lessened.  It  afterwards  became 
necessary  to  amputate  the  limb  on  ac- 
count of  another  disease.  The  operation 
was  performed  on  the  15th  of  December 
1808,  and  I  did  not  neglect  the  opportu- 
nity of  examining  the  joint. 

The  bones,  cartilages,  and  ligaments, 
were  in  a  natural  state.  The  synovial 
membrane  was  increased  in  thickness  to 
about  one-eighth  of  an  inch,  and  was  of 
a  gristly  texture.  It  was  closely  attached 
to  the  surroundinsc  cellular  membrane  and 
fascia  by  means  of  coagulable  lymph, 
which  had  been  formerly  effused  on  its 
external  surface. 


These  cases  seem  to  explain  the  usual 
consequences  of  inflammation  of  the  sy- 


(     15     ) 

novial  membrane.  It  occasions,  1  st,  a  pre- 
ternatural secretion  of  synovia;  2dly5  ef- 
fusion of  coagulable  lymph  into  the  cavity 
of  the  joint;  3dly,  in  other  cases  a  thicken- 
ing of  the  membrane;  a  conversion  of  it 
into  a  gristly  substance;  and  an  eifusion 
of  coagulable  lymph,  and  probably  of 
serum,  into  the  cellular  texture,  by  which 
it  is  connected  to  the  external  parts. 

I  have  seen  several  cases  where,  from 
the  appearance  of  the  joint,  and  other 
circumstances,  there  was  every  reason  to 
believe  that  the  inflammation  had  pro- 
duced adhesions,  more  or  less  extensive, 
of  the  reflected  folds  of  the  membrane  to 
each  other;  and  I  have  observed  occa- 
sionally in  dissection  such  partial  adhe- 
sions as  might  reasonably  be  supposed  to 
have  arisen  from  inflammation  at  some 
former  period. 

These  effects  of  inflammation  of  the 
synovial,  very  much  resemble  those  of 
inflammation  of  the  serous  membranes. 
There  are  however  some  points  of  dif- 


(  1«  ) 

ference.  In  the  latter,  it  is  not  very 
uncommon  for  suppuration  to  take 
place  independent  of  ulceration.  I  hare 
had  an  opportunity  of  examining  one 
case,  where  the  same  thing  had  occurred 
in  the  synovial  membrane  of  a  joint. 
The  elbow  was  found  filled  with  pus, 
although  there  was  no  ulcerated  sur- 
face. Here  the  inflammation  followed 
a  small  wound,  which  had  penetrated 
into  the  articular  cavity;  but  I  believe 
that  inflammation  of  the  synodal  mem^ 
branes,  which  has  not  had  its  origin 
in  mechanical  injury,  seldom  terminates 
in  this  manner.  Inflammation  of  the 
peritonaeum  or  pleura,  though  very  sliglit 
in  degree,  and  of  short  duration,  is  suffi- 
cient to  produce  an  eff'usion  of  coagulable 
lymph;  but  it  is  only  violent  or  long- 
continued  inflammation  which  has  the 
same  result  in  the  membranes  of  the 
joints. 

The  slight  adhesion  of  the  caililage  to 
the  bone  in  one  of  the  cases   which  have 


(     17     ) 

been  related,  we  must  suppose  to  have 
proceeded  from  the  greater  disease  in  the 
synovial  memhi*ane.     I  shall  have  occa- 
sion hereafter  to  remark,  that  the  same 
thing  may  sometimes  be  observed,  where 
the  cartilage  is  about  to  ulcerate.     I  have 
known  some  cases,  in  which  there  was 
extensive  destruction  of  the  cartilages  of 
a  joint,   and  which,  from   the   previous 
history  and   symptoms,  seemed  to  have 
been   the  consequence  of  neglected    in- 
flammation  of  the    synovial   membrane. 
That  this  should  happen  is  no  more  re- 
markable, than,  that  ulcer  of  the  cornea 
should   occasionally   be    induced  by  in- 
flammation of  the  tU7iica  conjunctiva  of 
the  eye.     At  the  same  time,  I  believe  it 
will  be  found  in   the  great   majority  of 
cases,  where  ulceration  of  the  cartilages  is 
combined  with  inflammation  of  the   sy- 
novial membranes,  that  the  former  is  the 
primary  affection,  and  that  the  latter  takes 
place  subsequently  in  consequence  of  the 
formation  of  an  abscess  in  the  articular 
cavity. 

4 


(  i^  ) 


Sect.  II. 

On  the  Causes  and  Symptoms  of  this 
Disease. 

It  is  evident  that  inflammation  may 
affect  the  synovial  membrane  of  a  joint, 
by  extending  to  it  from  some  of  the 
other  textures  of  which  the  joint  is  com- 
posed, or  that  it  may  have  its  origin  in 
the  membrane  itself.  My  present  ob- 
servations are  intended  to  relate  chiefly 
to  cases  of  the  latter  description;  and 
what  little  is  to  be  said  in  addition  re- 
specting those  of  the  former,  will  be 
better  introduced  hereafter. 

Although  no  period  of  life  is  altogether 
exempt  from  this  disease,  it  does  not 
occur  equally  in  persons  of  all  ages.  It 
very  seldom  attacks  young  children;  be- 
comes less  rare  as  they  approach  the  age 
of  puberty;  and  is  very  frequent  in  adult 
persons.      This   is   the  reverse  of  what 


(      19     ) 

happens  with  respect  to  some  of  the 
other  diseases,  to  which  the  joints  are 
liable,  and  a  knowledge  of  these  circum- 
stances will  be  found  of  some  importance 
to  the  surgeon,  in  assisting  him  to  form  a 
ready  diagnosis. 

Inflammation  of  the  synovial  mem- 
branes may  take  place,  as  a  symptom  of 
a  constitutional  affection,  where  the  sys- 
tem is  under  the  influence  of  rheuma- 
tism; where  mercury  has  been  exhibited 
improperly,  or  in  too  large  quantities; 
and  under  a  variety  of  other  circum- 
stances. But,  in  these  cases,  the  disease 
for  the  most  part  is  not  severe;  it  occa- 
sions a  preternatural  secretion  of  synovia; 
but  does  not  in  general  terminate  in  the 
effusion  of  coagulable  lymph,  or  in  thick- 
ening of  the  inflamed  membrane.  Some- 
times it  attacks  .  the  greater  number  of 
the  joints  at  the  same  instant,  and  even 
extends  to  the  synovial  membranes,  which 
constitute  the  bursai  mucosa?  and  sheaths 
of  the  tendons.     At  other  times  it  leavo^ 


(     20     ) 

one  part  to  attack  another,   and   several 
joints  are  affected  in  succession. 

In  other  cases,  the  disease  is  entirely 
local;  produced  by  a  sprain  or  other  in- 
jury;   or    the    application   of  cold;   and 
sometimes  arising  from  no  evident  cause. 
The  application  of  cold  is,  on  the  whole, 
the   most  frequent  source  of  the   com- 
plaint; and  hence  it  is  easy  to  explain, 
ifhy  it  occurs  much  more  frequently  in 
the  knee  than  in  any  other  joint;  and 
why  it  is  rare  in  the  hip  and  shoulder, 
which  are  defended  by  a  thick  mass  of 
muscles  from  the  influence  of  the  exter- 
nal temperature.     Where  the  inflamma- 
tion is  thus  confined  to  a  single  joint,  it  is 
more  probable  that  it  will  assume  a   se- 
vere character;  and  that  it  may  be  of  long 
duration.     It  leaves   the  joint   with   its 
functions  more  or  less  impaired;  and  oc- 
casionally terminates  in  its  total  destruc- 
tion.    In  itself  it  is  a  serious  disease,  but 
it  is  often  confounded  under  the  alarming 
name  of  white  swelling,  with  other  dis- 
eases, which  are  still  more  serious. 


(     2*      ) 

Inflammation  may  attack  the  synovial 
membranes  in  different  degrees  of  inten- 
sity; but  for  the  most  part  it  has  the 
form  of  a  chronic  or  slow  inflammation; 
which,  while  it  impaii's,  does  not  alto- 
gether destroy  the  functions  of  the  joint; 
and  which,  if  not  relieved  in  the  first  in- 
stance by  active  and  judicious  treatment, 
may,  like  a  chronic  ophthalmia,  continue 
for  weeks  or  months,  and  with  occasional 
recoveries  and  relapses  may  even  harass 
2,nd  torment  the  patient  during  several 
successive  years. 

In  the  first  instance,  the  patient  ex- 
periences pain  in  the  joint,  which  al- 
though it  affects  the  whole  articulation, 
is  often  referred  principally  to  one  spot, 
where  it  is  felt  more  severely  than  else- 
where. The  pain  usually  continues  to 
increase  during  the  first  week  -or  ten 
days,  when  it  is  at  its  height.  Some- 
times even  at  this  period  the  pain  is 
trifling,  so  that  the  patient  experiences 
but  little  inconvenience  from  it;  at  other 


(      22     ) 

times  it  is  considerable,  and  every  motion 
of  the  joint  is  distressing  and  difficult. 

In  the  course  of  one  or  two  days  after 
the  commencement  of  the  pain,  the  joint 
may  be  observed  to  be  swollen.  At  first, 
the  swelling  arises  entirely  from  a  pre- 
ternatural collection  of  fluid  in  its  cavity. 
In  the  superficial  joints,  the  fluid  may  be 
distinctly  felt  to  undulate,  when  pressure 
is  made  alternately  by  the  two  hands 
placed  one  on  each  side.  When  the  in- 
flammation has  existed  for  some  time, 
the  fluid  is  less  perceptible  than  before, 
in  consequence  of  the  synovial  membrane 
having  become  thickened;  or  from  the 
effusion  of  lymph  on  its  inner  or  outer 
surface;  and  in  many  cases,  where  the 
disease  has  been  of  long  standing,  al- 
though the  joint  is  much  swollen,  and 
symptoms  of  inflammation  still  exist,  the 
fluid  in  its  cavity  is  scarcely  to  be  felt. 
As  the  swelling  consists  more  of  solid 
substance,  so  the  natural  mobility  of  the 
joint  is  in  a  greater  degree  impaired. 


(     23     ) 

The  form  of  the  swelling  deserves  no- 
tice. It  is  not  that  of  the  articulating 
ends  of  the  bones,  and  therefore  it  differs 
from  the  natural  form  of  the  joint.  The 
swelling  arises  chiefly  from  the  distended 
state  of  the  synovial  membrane,  and 
hence  its  figure  depends  in  great  mea- 
sure on  the  situation  of  the  ligaments 
and  tendons,  which  resist  it  in  cer- 
tain directions,  and  allow  it  to  take 
place  in  others.  Thus,  when  the  knee 
is  affected,  the  swelling  is  principally 
observable  on  the  anterior  and  lower 
part  of  the  thigh,  under  the  exten- 
sor raiuscles,  where  there  is  only  a 
yielding  cellular  structure  between  those 
muscles  and  the  bone.  It  is  also  often 
considerable  in  the  spaces  between  the 
ligament  of  the  patella  and  the  lateral 
ligaments;  the  fluid  collected  in  the 
cavity  causing  the  fatty  substance  to  pro- 
trude in  this  situation,  where  the  re- 
sistance of  the  external  parts  is  less  tlian 
elsewhere.     In  the   elbow   the   swelling 


(     24     ) 

is  principally  observable  in  the  posterior 
part  of  the  arm,  above  the  olecranon, 
and  under  the  extensor  muscles  of  the 
fore-arm;  and  in  the  ankle  it  shews  itself 
on  each  side,  in  the  space  between  the 
lateral  ligaments,  and  the  tendons,  which 
are  situated  on  the  anterior  part.  In 
like  manner  in  other  joints,  the  figure  of 
the  swelling,  whether  it  arises  from  fluid 
alone,  or  joined  with  solid  substance,  de- 
pends in  great  measure  on  the  ligament? 
and  tendons  in  the  neighbourhood,  and 
on  the  degree  of  resistance  which  they 
afford;  and  these  circumstances,  though 
apparently  trifling,  deserve  our  attention, 
as  they  enable  us  more  readily  to  form 
our  diagnosis. 

In  the  hip  and  shoulder  the  disease 
occurs  less  frequently  than  in  the  super- 
ficial joints.  The  effused  fluid  here  can- 
not be  felt  to  undulate,  but  the  swelling  is 
perceptible  through  the  muscles.  When 
the  hip  is  affected,  in  the  first  instance  a 
tumefaction  may  be  observed  in  the  groin 


(     25     ) 

and  in  the  nates  also;  but  where  the 
disease  has  existed  for  some  time,  the 
nates  assume  a  flattened  appearance,  in 
consequence  of  the  glutsei  muscles  be- 
coming wasted  from  want  of  use.  The 
pain  is  usually  confined  to  the  hip  itself; 
but  I  have  known  some  cases,  in  which 
it  was  referred  to  the  knee  also.  These 
symptoms  to  a  certain  degree  correspond 
to  those  which  take  place  where  the 
cartilages  of  the  hip  are  ulcerated;  but 
attention  to  the  following  circumstances 
will  enable  us  to  distinguish  the  two 
diseases  from  each  other.  Where  the 
synovial  membrane  of  the  hip  is  inflamed, 
the  pain  is  more  severe  in  the  beginning 
than  in  the  advanced  stage  of  the  disease, 
and  it  never  amounts  to  that  excruciating 
sensation,  which  exhausts  the  powers  and 
spirits  of  the  patient,  who  labours  under 
the  other  affection;  the  pain  is  aggra- 
vated by  motion,  but  not  by  pressing  the 
cartilaginous  surfaces  against  each  other; 
so  that  it  does  not  prevent  the  weight  of 

5 


(      2b      ) 

ttie  body  being  supported  on  tbe  ufiectcd 
limb;  and  the  wasting  of  the  glutaji 
muscles  is  preceded  by  a  swollen  appear- 
ance of  the  nates. 

After    inflammation    of   the    synovial 
membrane  has  subsided,  the  fluid  is   ab- 
sorbed, and  in  many  instances  the  joint 
regains   its   natural  figure  and  mobility; 
but  in  the  majority  6f  cases,  stifiness  and 
swelling  remain.     Sometimes   thie   swel- 
ling has  the  same  peculiar  form,  Avhich  it 
possessed  while  the  inflammation  still  ex- 
isted, and  while  fluid  was  contained  in  the 
joint;  and  we  may  suppose,  that  it  depends 
principally  on   the  inner  surface   of  the 
synovial  membrane  having  a  thick  lining 
of  coagulable  lymph;  at  other  times  the 
swelling  has  the  form  of  the  articulating 
extremities  of  the  bones,  that  is,  nearly 
the  natural  form  of  the  joint,  and  it  pro- 
bably arises  from  the  thickened  state  of 
the    synovial   membrane.     From   which- 
ever of  these  causes  a  swelling  remains 
after  the  inflammation  has  subsided,  the 


(     27     ) 

j)fitient  is  very  liable  to  a  reciiiTence  of 
the  disease.  Whenever  he  is  exposed  to 
cold,  or  exercises  the  limb  in  an  unusual 
degree,  and  often,  without  any  evident 
reason,  the  pain  returns,  and  the  swellinjj; 
is  augmented.  In  those  cases,  where  the 
synovial  membrane  is  tliickened,  although 
the  fluid  which  had  been  eftiised  is  ah-' 
sorbed,  and  the  principal  swelling  has 
disappeared,  it  occasionally  happens  not 
only  that  a  certain  degree  of  inflam- 
mation still  lingers  in  the  part,  but  (hat 
it  continues  until  the  morbid  action  ex- 
tends to  the  other  textures;  and  ulti- 
mately ulceration  takes  place  in  the  car- 
tilages; suppuration  is  established,  and 
there  is  complete  destruction  of  the  ar- 
ticulating surfaces.  In  this  advanced 
stae*e,  if  we  wish  to  know  whether  tl»e 
inflammation  of  tlie  svnovial  membrane, 
or  the  ulceration  of  the  cartilages,  has 
been  the  primary  affection,  we  must 
form  our  judgment,  not  from  the  present 
symptoms,  but  from  the  proious  history 


(     28      ) 

of  the  case.  It  is  indeed,  often  difficuil 
to  procure  a  history  on  the  accuracy  of 
which  we  can  rely,  particularly  in  hos- 
pital practice;  but  this  is  of  the  less  im- 
portance, as  whatever  the  disease  may 
have  been  in  its  origin,  where  it  has  pro- 
ceeded so  far  as  has  been  described,  there 
is  no  difference  respecting  the  treatment,* 
and  for  the  most  part,  when  suppuration 
has  taken  place,  there  is  little  prospect 
of  advantage  from  any  thing,  except  the 
removal  of  the  limb  by  amputation. 

I  believe,  that  the  above  history  will 
be  found  applicable  to  the  majority  of 
cases,  in  which  this  disease  exists.  But  I 
have  before  observed,  that  inflammation 
may  affect  the  synovial  membranes  in 
dififerent  degrees  of  intensity;  and  oc- 
casionally it  will  be  found  to  be  more 
urgent  in  its  symptoms,  and  to  be  more 
rapid  in  its  progress,  than  what  has  been 
described;  having  the  characters  of  ah 
acute  instead  of  a  chronic  inflammation. 
Under  these  circumstances,  the  swelling 


(      29     ) 

takes  place  immediately  after,  or  at  the 
same  instant  witli,  the  first  attack  of  pain; 
there  is  redness  of  the  skin;  the  pain  is 
more  severe,  and  it  is  so  mach  aggravated 
by  the  motion  of  the  parts,  that  the  pa- 
tient keeps  the  joint  constantly  in  the 
same  position,  and  usually,  in  an  inter- 
mediate state,  between  that  of  flexion  and 
extension.  In  addition  to  these  symp- 
toms there  is  more  or  less  of  symptoma- 
tic fever  of  the  inflammatory  kind.  In  a 
few  days  the  disease,  if  left  to  itself, 
assumes  the  chronic  form;  or  perhaps, 
under  proper  treatment,  it  subsides  al- 
together. 

It  must  be  observed,  however,  that  the 
boundaries  of  acute  and  chronic  inflam- 
mation do  not  admit  of  being  very  well 
defined.  These  terms  accuratelv  enou«:h 
express  the  two  extremes;  but  there  are 
numerous  intermediate  degrees  of  inflam- 
mation, of  which  it  is  difiicult  to  deter- 
mine, whether  they  should  be  considered 
as  being  of  the  acute  or  clironic  kind.    On 


(      ^0      ) 

this  and  ou  many  other  occasions  tlic 
pathologist  must  be  conteiit,  if  he  can 
succeed  in  pointing  out  tlie  principal  va- 
rieties of  morbid  action  which  occur,  and 
the  symptoms,  wliich  they  produce,  in 
such  a  manner  as  will  enable  others,  with 
the  assistance  of  a  certain  degree  of  ori- 
ginal observation,  to  distinguish  those 
nicer  shades  in  the  characters  of  disease, 
which  language  is  inadequate  to  explain, 
but  a  knowledge  of  which  is  of  consider- 
able importance  in  medical  and  surgical 
practice. 

Sect.  III. 

Oil  the  Treatment  of  this  Llsease. 

In  those  cases,  in  which  inflammation 
of  the  synovial  membrane  has  arisen  from 
a  protracted,  or  ill-conducted  course  of 
mercury,  sarsaparilla  may  be  given  with 
some  advantage,  although  it  does  not 
exhibit  those  singular  powers  which  it 
is  known  to  possess   in  some  other  com- 


C     31      ) 

plaints,  which  spring  from  the  same 
source.  When  the  inflammation  is  con- 
nected with  rheumatism,  opium  conjoined 
with  diaphoretics,  preparations  of  the 
colchicum  autumnale,  and  such  other 
remedies,  may  be  employed,  as  are  ca- 
pable of  relieving  rheumatism  in  other 
textures.  In  some  other  instances,  when 
several  joints  have  been  affected  at  the 
same  time,  it  has  appeared  to  me  that 
the  patient  has  derived  benefit  from  the 
use  of  moderate  doses  of  some  mercurial 
preparation. 

The  principal  remarks,  however,  which 
I  have  to  make  at  present,  relate  to  the 
local  treatment  of  the  disease;  and  it  is 
w  orthj  of  notice,  that  even  in  those  cases 
where  it  is  evidently  dependent  on  some 
constitutional  affection,  topical  remedies 
are  on  the  whole  of  more  importance 
than  any  other. 

In  the  acute  form  of  the  inflammation 
leeches  may  be  applied  in  the  neighbour- 
hood of  the  part;  and  if  there  is  much 


(     32     ) 

symptoriiatic  fever,  blood  may  be  taken 
from  the  arm,  and  the  bleeding  may,  or 
may  not,  be  repeated  according  to  cir- 
cumstances. Attention  should  be  paid 
to  the  state  of  the  bowels,  and  saline 
draughts  may  be  given  with  some  dia- 
phoretic medicines.  If  the  swelling  has 
rapidly  risen  to  such  a  height,  as  to  occa- 
sion considerable  tension  of  the  soft  parts, 
the  pain  will  be  best  relieved  by  means 
of  warm  fomentations  and  poultices;  but 
otherwise  cold  evaporating  lotions  seem 
to  produce  a  better  effect.  Under  this 
treatment  tlie  acute  inflammation  in  ge- 
neral speedily  subsides. 

The  chronic  inflammation  is  relieved 
more  slowly.  In  the  first  instance  the 
joint  should  be  kept  in  a  state  of  perfect 
quietude.  Blood  should  be  taken  from 
the  part,  by  means  of  leeches  or  cupping. 
It  has  appeared  to  me,  that  the  latter 
method  is  preferable;  the  sudden  ab- 
straction of  blood,  which  can  be  thus 
effected,  being  more  beneficial  than  the 


(      33     ) 

more  gradual  lifemorrhage,  which  is  pro- 
cured by  leeches.  It  will  in  general  he 
right  to  repeat  the  hlood-letting  twice  or 
three  times,  or  even  oftener;  and  in  the 
intervals  compresses  may  he  laid  on  the 
part,  moistened  with  some  cold  lotion. 
After  the  violence  of  the  inflammation  is 
suhdued,  a  hlister  may  be  applied;  and 
(if  necessary)  several  blisters  may  he  used 
in  succession,  with  more  advantage  than 
a  single  hlister  kept  open  by  means  of 
savine  cerate.  The  blisters  should  be  of 
a  considerable  size;  and  if  the  affected 
joint  be  deep-seated,  they  may  be  applied 
as  near  to  the  joint  as  possible;  but  other- 
wise a  blister  is  frequently  of  more  ser- 
vice when  applied  at  a  little  distance. 
For  example,  if  the  synovial  membrane 
of  the  hip  be  inflamed,  the  blister  may  he 
placed  on  the  groin  aiid  nates;  but  if  the 
disease  be  in  the  wrist,  it  may  be  applied 
to  the  lower  part  of  the  fore-arm.  Under 
this  treatment  the  pain  is  usually  relieved, 
and  in  a  few  days  the  swelling,  as  far  as 

6 


(     34     ) 

it  depends  on  fluid  collected  in  the  joint. 
is  much  diminished.  Even  when  the 
tumor  is  solid,  arising  from  the  effusion 
of  coagulahle  lymph,  it  will  in  a  consider- 
able degree  subside,  and  sometimes  be  en- 
tirely dispersed,  provided  that  the  lympli 
has  not  yet  become  organized.  Blisters 
are  of  more  service,  with  respect  to  the 
removal  of  the  swelling,  than  any  other- 
remedies;  but  they  should  not  be  em- 
ployed without  the  previous  abstraction 
of  blood,  except  when  the  inflammation 
is  slight,  and  when  fluid  is  effused  with- 
out any  admixture  of  solid  substance. 

^Yhen  the  inflammation  is  in  great 
measure  relieved,  a  moderate  degree  of 
exercise  of  the  joint  is  beneficial,  rather 
than  otherwise.  Liniments,  which  irri- 
tate the  skin,  may  be  rubbed  on  twice 
or  three  times  in  the  day.  The  lini- 
ments of  the  Pharmacopceia  are  not 
sufficiently  stimulating  for  this,  nor  in- 
deed for  most  other  purpose^.  The 
lin'unentum  sapcnh^  or  Unlmcniiim  caui- 


(     35     ) 

phorx  compositum^  may  be  made  stronger 
by  the  addition  of  liquor  ammonix  and 
tinctura  lyttae;  and  tlie  powers  of  the  li- 
nimentum  ammonige  may  be  augmented  in 
the  same  manner,  or  by  tiie  addition  of 
the  oleum  terebinthins;.  The  following 
liniment  is  more  stimulating  than  those 
in  common  use,  and  seems  to  me  in 
many  cases  to  be  productive  of  mucli 
better  effects  with  respect  to  the  disease. 

R  Olei  Olivse  §  j  fs« 

Jicidi  Sulphurici  §  fb. 
M.  Fiat  linimentum* 

It  may  be  used  of  this  strength  for  the 
class  of  persons  who  apply  at  a  hospital 
for  relief;  but  for  those  of  a  higher  class 
in  society,  in  whom  the  cuticle  is  generally 
thinner,  and  the  cutis  more  tender,  the 
proportion  of  olive-oil  should  be  greater. 
The  effect  of  this  liniment  is  to  excite  some 
degree  of  inflammation  of  the  skin:  the 
cuticle  becomes  of  a  brown  colour,  and 
separates  in  thick,  broad  scales,  and  the 


(      36      ) 

iuii'ciinijiation  of  the  internal  parts  is  re- 
lieved, probably  on  the  same  principle  as 
by  a  blister.  Another  liniment,  which  is 
also  very  useful,  is  one  frequently  recom- 
mended, consisting  of  a  dram  (or  more) 
of  the  antimoniiim  tartarisatum  to  an 
ounce  of  the  unguentum  cetacei.  This 
produces  a  pustular  eruption  of  the  skin^ 
which,  like  other  eruptions  of  the  same 
kind,  runs  its  course,  and  during  a  cer- 
tain period  of  time  operates  very  be- 
neficially by  absti'acting  the  inflammation 
from  the  other  parts. 

IS^o  other  remedies  seem  to  be  produc- 
tive of  much  benefit. 

Plasters  of  gum  ammoniac,  and  others 
of  a  similar  nature,  are  of  little  efl&cacy, 
while  inflammation  still  exists;  but  after- 
wards they  are  sometimes  of  use  in  pro- 
tecting the  joint  from  the  influence  of  the 
external  cold,  and  preventing  a  relapse. 

Issues  and  setons  are  of  no  service, 
except,  when  there  is  reason  to  believe 
that  a  secondary  disease  has  begun   to 


(     37      ) 

take  place,  in  the  form  of  ulceration  of  tlie 
cartilages;  and  of  their  use,  under  these 
circumstances,  I  shall  have  occasion  to 
speak  hereafter. 

The  swelling  and  stiffness,  which  re- 
main after  the  inflammation  has  subsided 
may  be  relieved  by  the  free  exercise  of 
the  limb,  and  by  friction.  The  mercurial 
ointment  with  camphor  may  be  rubbed 
on  the  joint;  or  friction  may  be  made 
by  the  hand,  with  starch  or  other  fine 
powder.  The  friction,  however,  should 
be  employed  with  caution,  as,  when  used 
too  freely,  it  sometimes  occasions  a  re- 
turn of  the  inflammation.  Whenever 
there  is  the  slightest  indication  of  this 
being  the  case,  the  friction  should  be 
omitted,  blood  should  be  taken  from  the 
part,  and  some  time  should  elapse  before 
the  friction  is  resumed.  Friction  is  some- 
times productive  of  very  essential  benefit, 
but  not  unless  it  be  employed  to  a  con- 
siderable extent;  as  for  two  or  three  hours 
daily,  and  during  a  long  period  of  time. 


(     38     ) 

As,  however,  when  employed  in  this? 
manner,  it  is  likely  to  induce  a  return  of 
inflammation  in  parts  in  which  the  inflam- 
matory disposition  may  still  linger,  it  evi- 
dently is  a  remedy,  which  is  applicable 
only  under  certain  circumstances.  For 
these  reasons  it  is  that  friction  appears  to 
be  more  efficacious  where  the  stiffiaess  of 
a  joint  depends  on  a  contracted  state  of 
the  muscles  or  tendons  of  the  limb,  and 
on  these  being  glued  to  each  other,  and 
to  the  surrounding  parts,  than  where  it  is 
the  consequence  of  disease  in  the  joint 
itself. 

I  have  sometimes  tried  the  effect  of 
pumping  hot  water  on  a  stiff  joint,  as 
recommended  by  Le  Dran,  and  as  now 
practised  at  some  watering  places.  The 
blow  of  a  column  of  water,  falling  froin 
a  height  of  several  feet,  produces  con- 
siderable friction,  even  so  as  to  excoriate 
the  surface,  with  which  are  combined  the 
relaxing  powers  of  heat  and  moisture. 
This  practice   is  certainly  productive  of 


(      S9      ) 

benefit;  but  the  observations  just  made 
apply  to  tliis  as  well  as  the  other  modes 
of  producing  friction. 


Sect.  IV. 

Cases  of  Inflamed  Synovial  Membrane, 

The  cases  which  I  am  about  to  relate, 
will  serve  to  illustrate  some  of  the  ob- 
servations respecting  the  inflammation  of 
the  synovial  membrane,  which  I  have  al- 
ready made;  and  also  to  explain  sorae 
circumstances,  which  will  be  found  to 
occur  in  practice,  and  which  ccuM  not  so 
well  be  introduced  in  the  general  history 
of  the  disease,  contained  in  the  preceding 
pages.  TVhoever  will  take  the  pains  to 
compare  these  cases  with  each  other,  and 
with  those  which  I  shall  relate  hereafter, 
will,  if  I  am  not  exceedingly  mistaken, 
be  convinced,  that  the  distinction  of  the 
different  diseases  of  the  joints  is  not  a 
mere  matter  of  curiosity,  whicli  may  be 


(      JO      ) 

interesting  to  the  morbid  anatomist;  but 
that  these  diseases  are  different  in  their 
progress;  that  they  produce  different 
symptoms,  by  which  they  may  be  known 
from  each  other  in  the  living  person;  and 
which  indicate  the  employment  of  differ- 
ent remedies,  for  their  relief. 


CASE  III. 

John  Adams,  forty-seven  years  of  age, 
on  the  21st  of  August,  1811,  was  seized 
with  a  pain  in  his  left  knee,  and  in  the 
course  of  a  few  hours  he  found  the  joint 
to  be  swollen.  This  was  accompanied  by 
a  slight  attack  of  fever. 

On  the  28th  of  August  he  was  admit- 
ted into  St.  George's  Hospital.  At  this 
time  the  knee  Avas  extremely  painful  and 
tender,  and  much  swollen;  the  swelling 
not  having  the  form  of  the  articulating 
ends  of  the  bones,  but  being  most  pro- 
minent on  the  anterior  and  lower  part  of 
the  thigb,  underneath  the  lower  portion 


(   '^1   ) 

of  the  extensor  muscles.  The  fluctuation 
of  fluid  might  be  distinctly  felt,  within  the 
synovial  membrane. 

Eight  ounces  of  blood  were  taken  from 
the  knee  by  cupping.  The  loss  of  blood 
was  immediately  followed  by  an  abate- 
ment of  the  pain,  tenderness,  and  swelling. 
On  the  30th  of  August  a  blister  was 
applied. 

The  cupping  was  repeated  on  the  9tb 
and  iSth  of  September,  and  on  the  4th  of 
October,  and  each  time  was  followed  bj 
ihe  application  of  a  blister. 

On  the  10th  of  October  the  joint  was 
free  from  all  pain  and  tenderness.  It 
was  stifl^j  and  still  slightly  swollen,  but  no 
fluid  was  perceptible,  the  swelling  appear- 
ing to  arise  entirely  from  solid  substance. 
He  was  directed  to'  use  a  stimulating 
liniment  twice  in  the  day. 

On  the  l8th  of  October  there  had  been 
no  return  of  inflammation,  and  the  stiff- 
ness and  swelling  were  diminished.  Fric- 
tion was  now  employed,  by  means  of  the 

7 


(  -i^  ) 

hand  >vith  starch  powder  ever^  inoniing 
and  evening;  and  in  a  few  days  after- 
wards, it  was  directed,  in  addition  to  the 
friction  that  hot  water  should  be  pumped 
on  the  joint,  so  as  to  fall  on  it  from  a 
htischt  of  several  feet,  for  half  an  hour 
every  morning. 

About  the  middle  of  November  he  w  as 
dismissed  from  the  hospital;  the  joint 
being  now  nearly  as  small,  and  as  move- 
able as  before  the  inflammation  had  taken 
place. 

CASE  lY. 

Robert  Stewart,  eighteen  years  of  age, 
was  admitted  into  St.  George's  Hospital 
on  the  26th  of  January  1814. 

He  said,  that  about  seven  weeks  before 
his  admission,  the  right  knee  had  become 
swollen  and  painful  without  any  evident 
cause.  The  pain  and  swelling  took  place 
about  the  same  time.  The  pain  was 
severe,  and   attended  with  some   degree 


(     43     ) 

Of  fever.  About  a  fortnight  before  liis 
admission,  the  joint  was  cupped,  and  the 
swelling  and  pain  became  much  dimi- 
liished,  and  the  leg  more  moveable. 
The  cupping  had  been  repeated  on  the 
day  previous  to  his*  coming  to  the  hos- 
pital, and  again  aflorded  him  relief. 

At  the  time  of  his  being  admitted  into 
the  hospital,  the  knee  was  still  much 
swollen,  the  swelling  extending  up  the 
anterior  and  lower  part  of  the  thigh 
under  the  extensor  muscles:  and  it  ap- 
peared to  arise  chieHy  from  solid  sub 
stance  eifused  within  the  articulation, 
very  little  ildid  being  to  be  distinguished. 
There  was  but  little  pain  or  tenderness; 
the  joint  admitted  of  a  limited  motion;  he 
said,  it  was  less  stiifj  than  it  had  been  :>, 
short  time  before. 

On  the  27th  of  January  eight  ounces  of 
blood  were  taken  from  the  knee  by  cup- 
jilng.  and  afterwards  a  blister  was  apph'td. 

On  the  5th  of  February  the  blislei- 
\\  as  healed.     The  swelling' was  n^ucli  di- 


C      44     ) 

minished.      The   solid  substaricej  nlucb 
had  been  effused,  was  in  great  measure 
absorbed,  so  that  the  form  of  the  articu 
lating  ends  of  the  bones  could  be  distin- 
g'uished.   The  blister  was  repeated. 

On  the  48th  of  February,  the  joint  was 
scarcely  larger  than  natural,  but  it  was 
still  atiff  in  a  slight  degi-ec.  The  stiff- 
ness disappeared  under  the  employment 
of  friction  with  mercurial  ointment  and 
camphor,  and  on  the  23d  of  February 
he  was  dismissed  from  the  hospital  as 
ci:red, 

CASE  y. 

John  Hannam,  a  stout  middle-aged 
man,  was  admitted  into  St.  George's  Hos- 
pital under  Mr.  Keate,  on  the  22d  of  Ma> , 
1811. 

He  said  that  six  years  ago  he  had 
wrenched  his  right  knee,  which  in  a  few 
hours  became  swollen  and  painful.  In 
the  course  of  a  month  the  pain  and  the 


(     4f,     ) 

£wellirxg  gubsided,  and  he  returned  to  his 
duty  as  a  soldier,  in  one  of  the  regiments 
of  Life  Guards:  but  from  that  period  he 
experienced,  what  he  termed,  a  weakness 
of  the  joint,  and  he  had  a  return  of  pain 
and  swelling,  whenever  he  made  any 
unusual  exertion,  A  year  and  a  half 
previous  to  his  coming  to  the  liospitaL 
he  was  ill  of  a  fever.  From  this  time 
the  knee  was  more  sv/oiien  and  painful: 
and  he  continued  in  this  state,  sometimes 
better,  sometimes  worse,  so  that  be  was 
unable  to  do  his  dutj^  and  he  was  in  con- 
sequence  discharged  from  his  regiment.  , 
At  the  time  of  his  admission  the  knee 
was  swollen;  partly  from  fluid  in  its 
cavity,  partly  from  thickening  of  the  soft 
parts.  The  svrelling  extended  some  way 
up  the  anterior  part  of  the  thigh,  and 
was  prominent  on  each  side  of  the  liga- 
ment of  the  patella.  The  Joint  was  stiff, 
but  admitted  of  an  imperfect  i3exiou  and 
extension.  He  complained  of  some  de- 
gree of  pain  when  at  res(.  but  the   paifi 


(      "5      ) 

was  more  severe,  whenever  he  aUeiiipted 
to  exercise  the  limb.  There  was  an  en- 
larged lymphatic  gland  in  the  groin. 

The  knee  was  cupped  several  times, 
wldle  the  patient  remained  in  the  hos- 
pital. Blisters  and  stimulating  liniments 
were  employed,  and  about  the  end  ot* 
September  he  left  the  hospital,  better 
than  when  he  was  admitted;  but  there 
was  still  pain,  whenever  he  made  Any 
unusual  exertion,  and  the  joint  was 
swollen  and  stiff,  though  in  a  less  degree 
than  formerly.  The  swelling  now  appear- 
ed to  arise  altogether  from  solid  sub- 
stance, no  fluid  being  perceptible. 

Fifteen  months  afterwards  I  had  an 
opportunity  of  seeing  him  again.  Theie 
was  very  little  alteration  in  the  state  of 
the  knee.  He  said  that  whenever  lie 
took  more  exercise  than  usual,  or  was  ex- 
posed to  cold,  inflammation  took  place, 
and  the  sv>  elling  was  increased;  but  tliat 
by  remaining  for  a  sliort  time  in  a  state 
of  quietuflc  iliesc  symptoms  were  abun  s 
3'elievcd. 


(      47      ) 


The  iliree  preceding  cases  are  euIK 
cient  to  illustrate  the  ordinary  character^., 
and  the  ordinary  progress  of  this  disease. 
Those  which  follow  are  intended  to  explain 
certain  circumstances,  which  although  of 
h*ss  frequent  occurrence,  are  occasionally 
met  with,  and  which  it  is  of  much  conse- 
quence for  the  surgeon  to  understand. 


CASE  VI. 

A  young  gentleman,  about  thirteen 
years  of  age,  in  July  1817,  was  seized 
with  inflammation  of  the  synovial  mem- 
brane of  one  knee,  attended  with  the  usual 
symptoms.  Blood  was  taken  from  the 
knee  by  means  of  leeches  and  cupping.; 
and  cold  lotions  were  applied;  and  the  vio- 
lence of  the  inflammation  subsided.  In 
the  beginning  of  October  a  blister  was  ap- 
plied; and  at  the  end  of  0€to])er,  the  knee 
Ivas  in  the  following  state.     It  was  larger 


(      48      ) 

than  the  other;  the  swelling  having  the 
form  of  the  articulating  extremities  of 
the  bones,  and  appearing  to  arise  from  a 
thickened  state  of  the  synovial  mem- 
brane. The  joint  admitted  only  of  a 
limited  degree  of  motion,  and  the  motion 
of  it  beyond  a  certain  point  was  pro- 
ductive of  pain.  He  was  now  directed 
to  employ  friction  with  a  stimulating 
liniment. 

The  complaint  continued  very  nearly 
in  the  same  condition  until  the  middle 
of  I^ovember,  when  the  swelling  became 
suddenly  reduced,  and  almost  wholly  dis- 
appeared. But  on  the  same  day  he  com- 
plained of  an  acute  pain  in  his  head, 
shooting  from  the  temples  to  the  forehead 
just  above  the  eyebrow.  This  pain  went 
off  in  a  few  hours,  leaving  only  a  slight 
soreness^  and  for  several  days  it  returned 
periodically,  in  the  form  of  a  nocturnal 
paroxysm,  of  great  severity,  but  of  only  a 
few  minutes'  duration.  Leeches  and  blis- 
ters were  applied  both  to  the  head  and 


(     49     ) 

Jegs;  and  purgatives  were  administered. 
At  the  end  of  a  week  tbe  pain  ceased; 
])nt  he  was  seized  with  great  somnolencjj 
which  was  soon  followed  by  strabismus, 
partial  blindness,  and  almost  total  cessa- 
tion of  speech;  and  after  remaining  in 
jhis  state  about  a  week  he  died. 
The  body  was  not  examined. 

CASE  VII. 

James  Burton,  forty  years  of  age,  was 
admitted  into  St.  George's  Hospital  oa 
the  2d  of  June,  1813,  labouring  under  a 
complaint  of  his  left  knee.  He  said, 
that  two  years  ago  the  joint  became 
painful  and  swollen,  at  first  in  a  slight 
degree,  but  afterwards  the  pain  and 
swelling  increased;  and  he  observed  that 
the  symptoms  were  always  aggravated 
on  the  coming  on  of  cold  or  wet  weather. 
For  the  last  nine  months  he  had  been 
unable  to  use  the  joint,  sufficiently  to 
enable  him  to  attend  to  his  usual  occupuv 


(      50      ) 

lions.      Blisters  and  issues  bad  been  em- 
ployed at  various  times,  and  as  he  thought 
Avith    some    temporary    relief.      At   the 
time  of  his  admission  the  knee  was  swollen 
in  consequence   of  fluid  being  collected 
Avithin  the   cavity  of  the  synovial  mem- 
brane.     The   fluid  miojht   be   distinctly 
felt  to  fluctuate  underneath  the  patella 
when  the   two   hands  were  placed,  one 
on  each  side  of  the  joint.     The  soft  parts 
were    somewhat,    but    not    considerably 
thickened.     He  had  very  little  pain  ex- 
cept on  motion;  was  unable  to  bend  the 
leg  beyond   the   right   angle,  but  could 
extend   it  completely.     The  swelling  of 
the  joint  appeared  greater  than  it  really 
was,   on    account  of  the  wasting  of  the 
muscles  of  the  thigh  and  leg. 

Blood  was  taken  from  the  knee  by 
means  of  cupping;  and  afterwards  several 
blisters  were  applied  in  succession.  He 
took  five  grains  of  the  pihila  hydrargyri 
submuriatis  every  night.  On  the  2d  of 
August  a  blister  was  applied,  and  kept 


(     51     ) 

open  by  dressing  it  with  the  sayine 
cerate.  At  the  end  of  three  weeks  he 
complained  of  pain;  and  a  sense  of  irrita- 
tion, extending  up  the  thigh  and  down 
the  leg.  These  symptoms  were  attri- 
buted to  the  open  blister,  and  were  im- 
mediately relieved  when  the  blistered 
surface  was  allowed  to  skin  over.  On 
the  20th  of  September  he  quitted  the 
hospital,  being  free  from  all  his  former 
symptoms,  except  that  there  was  still  a 
slight  degree  of  stiffness  of  the  joint. 

In  the  beginning  of  July,  1815,  the 
same  patient  came  again  under  my  ob- 
servation. At  this  time,  both  knees  were 
distended  with  fluid;  the  right  shoulder 
was  swollen,  but  in  a  less  degree:  and  there 
was  a  collection  of  fluid  in  the  synovial 
membrane,  which  forms  the  sheath  of  the 
tendons,  on  the  posterior  part  of  each 
wrist.  On  examining  the  right  knee, 
which  was  the  most  swollen  of  the  two,  a 
sensation  was  communicated  to  the  hand. 
as  if  produced   by   a  number  of  small 


(     52     ) 

loose  substances,  of  a  soft  consistence, 
within  the  canity  of  the  joint;  and  just 
perceptible  to  the  touch.  The  joints 
were  moveable,  and  very  little  painful. 
He  said  that  all  these  swellings  had  be- 
gun about  three  months  after  he  formerly 
quitted  the  hospital,  with  a  slight  degree 
of  pain,  and  had  gradually  increased. 

I  suspect  the  loose  substances,  which 
Avere  felt  within  the  knee  in  this  case,  to 
have  been  portions  of  coagulable  lymph, 
which  had  been  effused  on  the  inner  sur- 
face of  the  synovial  membrane,  and  after- 
wards had  become  detached;  similar  to 
those,  which  are  sometimes  formed  in 
the  cavity  of  an  inflamed  bursa  mucosa, 
and  which  I  shall  have  occasion  to 
describe  hereafter.  I  had  not  the  op- 
portunity of  observing  the  subsequent 
progress  of  the  disease  in  this  patient; 
and  I  have  never  been  able  to  ascertain 
the  correctness  or  incorrectness  of  this 
opinion,  respecting  these  loose  substances, 
by  dissection.     They  are  certainly  of  a 


(     53     ) 

different  nature  from  the  loose  cartilagesj 
tvhich  are  met  with  in  other  cases. 


CASE  VIII. 

Amy  Brookes,  fifty-four  years  of  age^ 
Was  admitted  into  St.  George's  Hospital 
on  the  10th  of  June,  1818. 

Three  years  ago,  her  right  knee  became 
swollen  and  painful,  and  the  pain  and 
swelling  had  existed  ever  since,  some- 
times in  a  greater,  sometimes  in  a  less 
degree.  At  the  time  of  her  admission, 
the  knee  was  much  swollen,  in  conse 
ijuence  of  fluid  collected  in  its  cavity. 
There  was  pain  in  the  joint,  which  was 
aggravated  by  motion;  but  which  was 
not  sufficient  to  interfere  with  her  rest  at 
night,  or  to  prevent  her  going  about  her 
usual  occupations.  On  examining  the 
knee,  a  sensation  was  given  to  the  hand, 
as  if  some  soft  loose  substance  was  formed 
within  the  joint;  and  a  crepitus  was  dis- 
tinguished, on  moving  the  patella  from 
one  side  to  the  other. 


(     54     ) 

During  tlie  time  of  her  stay  in  the  hospi^ 
tal,  blood  was  taken  from  the  knee  twice 
by  cupping,  and  once  by  leeches;  and 
two  blisters  were  applied.  July  ISth,  she 
was  discharged  as  cured;  there  was  no 
pain  nor  swelling;  the  loose  substance 
was  no  longer  perceptible,  and  the  cre- 
pitus could  scarcely  be  distinguished. 

The  crepitus  which  was  observed  in  this 
case,  occurs  only  in  a  few  instances,  and 
I  know  not  from  what  cause  it  proceeds. 
It  is  different  from  that  which  I  ha>e 
met  with  where  there  has  been  reason  to 
believe  that  the  cartilages  are  destroyed 
so  as  to  expose  the  bone  underneath. 


The  followinsc  case  furnishes  an  e\- 
ample  of  a  disease,  which,  as  far  as  I 
know,  has  not  been  described  by  any 
pathological  or  surgical  writer.  One  of 
the  most  remarkable  symptoms,  which 
the  disease  produces,  is  an  inflammation 
of  tlic    synovial  membranes;   for   whitli 


(     55     ) 

• 

reason  it  Is  to  be  rco'arded  as  connected 
with  the  present  subject,  and  may  be  pro- 
perly introduced  in  this  place. 

CASE  IX. 

A  gentleman,  forty-five  years  of  age,  in 
the  middle  of  June,  1817,  became  af- 
fected with  symptoms  resembling  those 
of  gonorrhoea.  There  was  a  purulent 
discharge  from  the  urethra,  with  ardor 
urinse  and  chordee.  On  the  23d  of  June 
he  first  experienced  some  degree  of  pain 
in  his  feet.  On  the  24th  the  pain  in  the 
feet  was  rather  increased,  but  not  in  a 
sufficient  degree  to  prevent  his  walking 
four  miles.  There  was  some  appearance 
of  inflammation  of  his  eyes. 

June  25th,  the  pain  in  his  feet  was 
more  severe;  the  tunicse  conjunctiva;  of 
his  eyes  were  much  inflamed,  with  a  pro- 
fuse discharge  of  pus. 

These,  symptoms  increased  in  violence, 
the  pulse   varying  from  SO  to    90  in  a 


(     5b     ) 

minute;  the  tongue  being  furred;  and 
tlie  patient  being  restless  and  uncomfort- 
able during  the  niglit.  The  whole  of  each 
foot  became  swollen;  there  was  inflam- 
mation of  the  synovial  membranes  of  the 
ankles;  and  it  appeared  to  me,  that  the 
affection  of  the  feet  themselves  arose 
from  inflammation  of  the  synovial  mem- 
branes belonging  to  the  joints  of  the 
tarsus,  metatarsus,  and  toes.  He  said 
that  he  could  compare  the  pain,  which 
he  experienced,  to  nothing  else  than  that 
which  might  be  supposed  to  arise  from 
the  feet  being  squeezed  in  a  vice. 

On  the  27th  of  June  the  left  knee  be- 
came painful,  and  on  the  following  day 
the  synovial  membrane  of  this  joint  was 
found  exceedingly  distended  with  syno- 
via. He  was  now  completely  crippled; 
compelled  to  keep  his  bed,  and  scarcely 
able  to  vary  his  position  in  the  smallest 
degree  without  assistance.  The  inflam> 
mation  of  the  eyes  and  urethra  was  8ome« 
what  abated. 


(  •"  ) 

June  30th,  the  inflammation  of  tlie 
eves  and  urethra  had  much  subsided, 
and  the  purulent  discJiarj^'e  was  dimi- 
nished. The  pains  of  his  joints  were  less 
severe;  and  the  feet  were  less  swollen. 
On  the  following  day  the  knee  was  less 
swollen  also. 

He  continued  to  mend,  and  on  the 
lOlh  of  July  the  swelling  of  the  feet  was 
still  further  diminished,  and  that  of  the 
knee  had  almost  wholly  disappeared. 
His  pulse  continued  to  vary  from  80  to 
90  in  a  minute,  and  his  tongue  was  still 
furred.  He  had  pain  in  the  feet  and 
knee,  but  less  severe  than  formerly,  and 
he  was  restless  at  night. 

July  13th,  he  complained  of  pain  in 
the  right  knee,  and  on  the  following  day 
there  was  pain  also  of  the  right  elbow 
^nd  shoulder. 

The  right  knee  afterwards  became 
swollen  from  fluid  within  the  cavity  of 
the  synovial  membrane,  but  not  in  the 
same  dea:ree  with  the  other  knee,  and 


(     58     ) 

the  swelling  soon  subsided.  There  was 
never  any  perceptible  swelling  of  the 
shoulder  and  elbow. 

August  1st,  all  his  pains  were  abated. 
The  eye  and  the  urethi'a  were  nearly  free 
from  inflammation,  and  the  purulent  dis- 
charge was  scarcely  perceptible. 

August  5th,  he  was  free  from  pain  ex- 
cept on  motion:  the  joints,  which  had 
been  affected,  were  stiff;  but  he  was  able 
to  move  about  on  crutches. 

From  this  time  he  progressively 
mended.  The  stiffness  of  the  joints  di- 
minished very  slowly;  but  he  was  free 
from  all  uneasiness.  He  was  longer  in 
recovering  the  use  of  the  shoulder,  than 
that  of  the  other  joints. 

In  the  following  December.  1817,  (at 
wbich  time  he  had  nearly,  but  not  com- 
pletely recovered  the  use  of  his  limbs,) 
he  had  another  attack  of  the  complaint. 
The  symptoms  were  the  sa:iie  as  for- 
merly, taking  place  in  the  same  order, 
and  pursuing  the  same  course,  but  with 


(     59     ) 

a  much  less  degree  of  violence.  This 
second  attack  lasted  about  six  weeks;  and 
left  him  again  considerably  crippled. 

In  March,  1818,  he  became  affected 
with  an  ophthalmia,  but  of  a  different 
nature,  from  that  which  he  laboured 
imder  in  the  preceding  summer.  The 
inflammation  was  seated  in  the  proper 
tunicks  of  the  eye;  and  it  appeared  pro- 
bable, that  it  would  speedily  haye  ter- 
minated in  adhesions  of  the  iris,  and 
destruction  of  the  powers  of  vision,  if 
it?  progress  had  not  been  arrested,  by 
repeated  blood-lettings,  and  the  use  of 
mercury. 

In  order  that  the  history  of  the  dis- 
ease might  be  rendered  as  simple  as 
possible,  I  have  described  the  symptoms 
in  this  case  without  hitherto  adverting  to 
the  treatment,  which  v.as  employed. — 
Leeches,  and  blisters  to  the  knee;  lini- 
ments rubbed  on  the  knees  and  shoul- 
ders; and  fomentations  when  there  wa^j 
severe    pain;    formed    the    principal    to- 


(     60     ) 

pical  remedies.  Of  the  various  medicines, 
which  were  exhibited,  none  seemed  to  he 
productive  of  benefit  with  the  exception 
of  the  vinum  colchici.  It  was  under  the 
use  of  this  medicine,  that  not  only  the 
pains  and  swellings  of  the  joints;  but 
that  even  the  purulent  inflammation  of 
the  eyes  and  urethra  first  began  to  sub- 
side: and  I  am  on  the  whole  inclined  to 
believe  that  my  patient  was  indebted  to 
it  for  a  much  more  speedy  recovery  than 
he  would  have  had  other^vise. 


I  have  had  the  opportunity  of  seeing 
four  other  cases,  in  which  a  similar  train 
of  symptoms  took  place. 

One  gentleman  lias  had  as  many  as 
eight  attacks  of  this  complaint.  Tlie  first 
took  place  when  lie  v.as  under  twenty 
years  of  age,  and  tlie  others  at  various 
intervals  in  the  course  of  the  next  seven- 
teen years.  In  one  of  them  the  first 
symptom  was   inflammation   of  the  urc- 


(     61      ) 

thra^  attended  with  a  discharge  of  pus, 
although  from  particular  circumstances  he 
could  not  helieve  that  he  had  been  ex- 
posed to  the  risk  of  infection.  This  was 
followed  by  purulent  ophthalmia,  and  that 
by  inflammation  of  the  synovial  mem- 
branes. In  three  of  the  attacks  a  puru- 
lent ophthalmia  was  the  first  symptom; 
which  was  followed  by  inflammation  and 
discharge  from  tlie  urethra;  and  then 
the  synovial  membranes  became  affected: 
and  in  the  other  four  attacks  the  affec- 
tion of  the  synovial  membranes  took 
place  without  any  preceding  inflammation 
either  of  the  eye  or  urethra.  The  dis- 
ease was  not  confined  to  the  synovial 
membranes  of  the  joints,  but  those  of 
the  bursffi  mucosae  were  inflamed  also. 
In  some  of  the  attacks  the  muscles  of  the 
abdomen  were  painful  and  tender,  and 
subject  to  spasmodic  contraction;  and 
there  was  an  occasional  impediment  to 
breathing,  which  seemed  to  arise  from 
a  similar  affection  ol'the  diaphragm.  The 
acute  form  of  the  disease,  in  this    case, 


(      62      ) 

lasted  from  six  weeks  to  three  months, 
but  nearly  a  year  generally  elapsed  before 
the  use  of  the  limbs  was  perfectly  re- 
stored. The  last  attack  began  in  July, 
1817;  and  in  the  beginning  of  May, 
1818,  while  he  was  still  lame,  he  was 
seized  with  a  very  violent  inflammation 
of  the  sclerotic  coat  and  iris  of  one  eye, 
which  was  suhdued  by  very  copious 
hlood-letting,  and  the  exhibition  of  mer- 
cury. 

Another  gentleman  gave  the  following 
history  of  his  complaints:  In  the  year 
1809,  he  had  symptoms  resembling  those 
of  gonorrhoea,  and,  when  these  had  con- 
tinued for  some  time,  one  testicle  became 
inflamed  and  swollen.  This  was  followed 
by  a  purulent  ophthalmia,  and  inflam- 
mation of  the  synovial  membranes.  In 
the  year  1814,  he  had  a  similar  attack, 
Avith  the  exception  of  the  swelled  tes- 
ticle; and  in  the  year  18 16,  when  I 
was  consulted,  he  still  laboured  under  a 
chronic  inflammation  of  the  synovial 
membranes  of  the  knees  and  ankles,  the 


(    es    ) 

<!on sequence  bf  the  last  attack,  and  by 
which  his  lower  limbs  were  completely 
crippled. 

In  the  fourth  case  the  patient  laboured 
under  a  severe  ophthalmia,  which  was  fol- 
lowed by  inflammation  of  the  urethra, 
and  then  the  joints  became  affected:  but 
I  had  lio  opportunity  of  watching  the 
progress  of  this  case,  nor  have  I  heard 
any  other  particulars  of  it. 

In  the  fifth  case  the  patient  laboured 
under  strictures  of  the  urethra.  He  had 
had  four  attacks  of  the  disease  which  has 
been  just  described  in  the  course  of  a  few 
years.  The  inflammation  of  the  urethra 
was  in  all  of  them  the  first  symptoms; 
which  was  followed  by  purulent  oph- 
thalmia, and  afterwards  by  inflammation 
of  the  synovial  membranes,  and  swelling 
of  nearly  all  the  joints.  In  two  of  these 
attacks,  he  attributed  the  discharge  from 
the  urethra  to  his  having  received  the 
infection  of  gonorrhoea,  and  in  the  two 
others  to  the  use  of  the  bougie. 


CHAP.  II. 

ON     ULCERATION    OF    THE     SYNOVIAL 
MEMBRANE. 

When  an  abscess  has  formed  in  a  joint, 
an  ulcerated  opening  takes  place  in  the 
synovial  membrane,  through  which  the 
matter  is  discharged.  The  following  are 
the  only  cases,  which  have  come  under  my 
observation,  where  ulceration  of  the  syno- 
vial membrane  has  occurred  as  a  primary 
affection.  The  most  remarkable  circum- 
stance which  they  demonstrate  is,  that  a 
disease,  apparently  slight,  and  of  a  part, 
which  is  in  no  way  concerned  in  the  vital 
functions,  should  produce  such  a  degree  of 
disturbance  of  the  constitution  as  to  oc- 
casion death.  Of  this,  however,  they 
form  by  no  means  a  solitary  example,' 
and  every  surgeon  and  physiologist  will 
be  able  to  call  to  mind  numerous  other 
instances  which  show  that  an  impression 
made  upon  a  small  part  of  the  nervous 


(     65     ) 

system  may  derange,  and  ultimately  de- 
stroy, the  functions  of  the  whole  animal 
machine. 


CASE  X. 

A  young  lady,  nine  years  of  age,  heing 
at  play,  on  the  1st  of  January,  1808,  fell 
and  wrenched  her  hip.  She  experienced 
so  little  uneasiness,  that  she  walked  out 
on  that  day  as  usual.  In  the  evening 
she  went  to  a  dance;  but  while  there 
was  seized  with  a  rigor;  was  carried 
home  and  put  to  bed.  N'ext  morning 
she  was  much  indisposed,  and  complained 
of  pain  in  the  thigh  and  knee:  on  the 
following  day  she  had  pain  in  the  hip,  and 
was  very  feverish.  These  symptoms  con- 
tinued; she  became  delirious;  and  she 
died  just  a  week  from  the  time  of  the 
accident. 

On  inspecting  the  body  on  the  follow- 
ing day,  the  viscera  of  the  thorax  and 

10 


(      66      ) 

abdomen  were  found  in  a  pcriectly 
healthy  state.  The  hip-joint  on  the  side 
of  the  injury  contained  about  half  an 
ounce  of  dark-coloured  pus:  and  the  sy- 
novial membrane,  where  it  was  reflected 
over  the  neck  of  the  former,  was  de- 
stroyed by  ulceration,  for  about  the  ex- 
tent of  a  shilling. 


CASE  XL 

A  middle-aged  man,  who  had  met  with 
a  contusion  of  one  shoulder,  was  admitted 
into  St.  George's  Hospital  in  the  winter 
of  1812.  He  complained  of  pain  and  ten- 
derness of  the  shoulder,  and  a  very  slight 
degree  of  swelling  was  observable:  but 
his  principal  disease  was  a  fever,  resem- 
bling typhus  in  its  character,  of  which  he 
died  in  a  few  days  after  his  admission. 

On  inspecting  the  body,  about  half  an 
ounce  of  thin  pus  was  found  in  the 
shoulder-joint.     The  synovial  membrane 


(     67     ) 

bore  marks  of  general  inflammation,  and 
in  one  spot,  where  it  was  reflected  over 
the  neck  of  the  os  brachii,  it  was  de- 
stroyed by  ulceration  for  about  the  extent 
of  a  sixpence. 


CHAP.  111. 

ON  CASES,  IN  WHICH  THE  SYNOVIAL  MEM- 
BRANE HAS  UNDERGONE  A  MORBID  CHANGE 
OF   STRUCTURE. 


Sect.  I. 

Pathological  Observations. 

There  are  some  diseases,  wliich  consist 
simply  in  a  morbid  action;  there  are 
others,  in  which  the  morbid  action  pro- 
duces a  morbid  change  of  anatomical 
structure. 

Diseases  of  the  latter  class  differ  in 
their  nature  in  different  organs.  Thus 
the  tubercles,  which  affect  the  lungs  in 
phthisis  pulmonalis,  are  never  met  with 
in  the  breast;  and  cancer,  which  is  fre- 
quent in  the   breast,  never   attacks    the 


(      69      ) 

lungs,  except  by  extending  to  th^em  from 
the  contiguous  parts. 

The  disease,  which  I  am  about  to  de- 
scribe in  the  present  chapter,  consists  in 
a  morbid  alteration  of  structure,  which 
takes  place  in  the  synovial  membranes  of 
joints,  and  which,  as  far  as  I  have  seen, 
is  peculiar  to  these  parts.  I  have  never 
known  an  instance  of  the  same  disease  in 
the  serous  membranes,  which  so  nearly 
resemble  the  former  in  their  nature  and 
functions;  nor,  even,  in  the  synovial 
membranes,  that  constitute  the  bursse 
mucosseand  sheaths  of  the  tendons. 

Several  years  since,  in  examining  a  dis- 
eased elbow,  1  found  the  cartilaginous 
surfaces  completely  destroyed  by  ulcer- 
ation: an  abscess  had  formed  in  the  joint, 
and  no  remains  were  observable  of  the 
natural  structure  of  the  soft  parts,  these 
being  every  where  converted  into  a  pulpy 
substance,  of  a  light  brown  colour,  and 
about  one-third  of  an  inch  in  thickness. 
As  the  ravages  of  t!ie  disease  were  very 


(    '?o    ) 

extensive,  it  was  impossible  to  determine 
from  the  appearances  on  dissection,  where 
the  morbid  action  had  originated.  This 
case,  however,  differed  materially  from 
some  others  w hich  I  had  met  with,  in 
which  the  destruction  of  the  cartilages 
was  not  attended  b}'  any  affection  of 
the  soft  parts  similar  to  that,  which  has 
been  described.  The  following-  cases, 
which  hare  since  occurred,  furnisli  ex- 
amples of  the  same  disease  in  eai'lier 
stages  of  its  progress,  and  shew  that  it 
begins  in  the  synovial  membrane,  and 
that  the  other  parts  become  affected  only 
in  a  secondary  manner. 


CASE  XII. 

In  a  diseased  knee,  which  was  ^i^nt  to 
liie  for  examination  bv  mv  freind  the  late 
Mr.  Horn,  surgeon  to  the  ]S"ewcastle  In- 
lii-mury,  I  found,  in  the  ca>ity  of  tlie 
joint,  about  four  ounces  of  a  pale  yellow 
fluid,  having  Hakes  of  coagulablc  lymph 


(     71     ) 

floating  in  it.  The  synovial  membrane, 
where  it  formed  the  loose  folds,  extending 
from  one  bone  to  the  other;  where  it 
was  reflected  over  the  bones  themselves, 
the  crucial  ligaments,  and  the  fatty  sub- 
stance of  the  joint;  had  completely  lost  its 
natural  appearance.  It  was  converted  into 
a  pulpy  substance,  in  most  parts  about  a 
^juarter,  but  in  some  parts,  nearly  half 
an  inch  in  thickness,  of  a  light  brown  co- 
lour, intersected  by  white  membranous 
lines,  and  with  red  spots  formed  by  small 
vessels  injected  with  their  own  blood. 
The  synovial  membrane  on  the  edge  of 
the  cartilaginous  surfaces  had  undergone 
a  similar  change  of  structure,  but  only 
for  a  small  extent.  The  semilunar  carti- 
lages were  entire,  but  in  a  great  measure 
concealed  by  the  pulpy  substance  project- 
ing over  them.  The  cartilages  covering 
the  bones,  in  a  few  places  were  in  a  state 
(Of  incipient  ulceration. 


C      72      ) 

CASE  XIII. 

Martha  Manners,  twenty-six  years  of 
age,  was  admitted  into  St.  George's  Hos- 
pital on  the  6th  of  March,  1813,  on  ac- 
count of  a  disease  in  her  right  knee. 

She  said  that  in  June,  1811,  she  first 
observed  the  joint  to  be  swollen  and  stiff; 
and  from  this  time,  the  swelling  and  stiff- 
ness increased;  but  in  the  first  instance 
by  very  slow  degrees.  About  IVIichael- 
mas,  1812,  she  caught  cold,  and  the 
swelling  increased  more  rapidly,  but  it 
was  not  attended  with  any  considerable 
quantity  of  pain. 

At  the  time  of  her  admission  into  the 
hospital,  the  right  knee  measured  about 
two  inches  in  circumference  more  than 
the  left.  The  swelling  was  elastic;  pro- 
minent at  the  upper  and  lower  part  of  the 
joint;  not  having  the  form  of  the  articu- 
lating ends  of  the  bones.  The  joint  ad- 
mitted of  motion,  but  the  leg  could  not 


(     73     ) 

be  completely  bent  or  extended  on  tlie 
thigh. 

Various  remedies  were  employed  with- 
out the  smallest  benefit.  The  stiffness 
of  the  joint  increased.  About  the  middle 
of  May,  she  began  to  experience  consi- 
derable pain,  and  soon  afterwards  an 
abscess  presented  itself  by  the  side  of 
the  ligament  of  the  patella,  which  was 
opened  on  the  15th  of  June.  The  orifice 
made  by  the  lancet  healed  in  a  few  days; 
but  she  continued  to  suffer  severe  pain; 
her  health  became  much  affected,  and  on 
the  6th  of  August  the  limb  was  removed 
by  amputation. 

On  examining  the  joint,  about  an 
ounce  of  thick  matter  was  found  in  its 
cavity.  The  ligaments  were  in  a  natural 
state.  The  synovial  membrane  had  un- 
dergone precisely  the  same  alteration,  as 
in  the  case  which  has  just  been  related. 
The  only  point  of  difference  that  could 
be  observed,  was,  that  the  whole  of  that 
portion  of  the  membrane,  which  is  re- 
11 


(     74     ) 

fleeted  over  the  cartilages,  had  become 
affected,  presenting  the  same  appearance 
as  elsewhere,  but  being  thickened  in  a 
less  degree.  The  cartilages  had  begun  to 
ulcerate  in  a  few  spots;  but  the  ulceration 
had  made  so  little  progress,  that  it  might 
not  have  been  noticed  on  a  superficial  in- 
spection. 

CASE  XlV. 

Samuel  Langford,  24  years  of  age,  was 
admitted  into  St.  George's  Hospital  on  the 
22d  of  April,  1812. 

At  the  time  of  his  admission,  one  of 
his  knees  was  swollen  to  nearly  twice  its 
natural  size.  The  swelling  was  promi- 
nent on  the  anterior  and  lower  part  of 
the  thigh.  It  was  soft  and  elastic,  so 
that  at  first  it  appeared  to  contain  fluid, 
but  on  particular  examination,  the  ab- 
sence of  fluid  was  ascertained,  by  the 
want  of  fluctuation.  The  leg  was  kept 
in  the  half-bent  state,  and  the  joint  ad- 


(     75     ) 

mitted  of  only  a  very  limited  degree  of 
motion.  He  had  no  pain,  even  when 
attempts  were  made  to  move  tJie  limh. 
The  skin,  over  the  diseased  part,  was  of 
a  pale  colour,  with  some  dilated  veins 
ramifying  in  it.  On  each  side  of  the 
joint,  a  small  orifice  was  observed,  through 
which  the  probe  might  he  introduced 
into  a  sinus;  hut  the  sinuses  appeared  to 
be  of  small  extent.  His  general  health 
was  unimpaired.  He  said,  that  two  years 
ago,  he  first  experienced  some  pain  in 
the  knee,  but  it  was  not  sufficient  to  pre- 
vent his  going  about  his  usual  occupa- 
tions. Soon  afterwards  the  joint  began 
to  swell,  and  the  enlargement  gradually 
increased  from  that  period.  Several  ab- 
scesses had  formed  at  different  times,  but 
the  greater  number  of  them  had  healed. 

About  two  months  after  his  admission 
into  the  hospital,  the  limb  was  amputa- 
ted. 

On  dissecting  the  diseased  joint,  the  li- 
gaments were  found  in  a  perfectly  natural 


(     76     ) 

State.  The  whole  synovial  membrane, 
except  where  it  was  reflected  over  the 
cartilages,  was  converted  into  a  pulpy, 
elastic  substance,  of  a  brown  colour,  in- 
tersected by  white  membranous  lines,  in 
some  places  half  an  inch  in  thickness,  in 
others  more;  and  in  those  parts,  where 
the  membrane  was  reflected  over  the 
bones,  near  the  border  of  the  cartilages,  it 
was  destroyed  in  spots  by  ulceration. 

The  semilunar  cartilages  were  in  a 
natural  state,  but  in  a  great  measure  con- 
cealed, in  consequence  of  their  being  en- 
veloped in  the  mass  of  substance  formed 
by  the  diseased  synovial  membrane.  The 
cartilaginous  surfaces  of  the  femur  and 
patella  .were  extensively,  but  not  entirely 
destroyed  by  ulceration;  the  ulceration 
being  greatest  towards  the  circumference. 
On  the  internal  portion  of  the  head  of 
the  tibia,  the  cartilage  was  destroyed  only 
for  a  very  small  extent,  the  ulceration 
being  entirely  confined  to  the  margin. 
On  the  external  portion  of  the  liead  of 


(  "  ) 

the  tibia,  the  cartilage  was  absorbed  to  a 
greater  extent.  The  bones  possessed 
their  natural  structure  and  hardness. 
The  cavity  of  the  joint  contained  matter, 
and  the  sinuses  communicated  with  it. 

CASE  XV.      , 

Michael  Purcel,  sixteen  years  of  age, 
was  admitted  into  St.  George's  Hospital, 
on  the  10th  of  July,  1811,  on  account  of 
a  disease  in  the  right  knee. 

He  said  that  in  the  summer  of  1807, 
he  had  received  a  blow  on  the  inside  of 
the  joint.  Some  time  afterwards  a  swel- 
ling formed  and  burst,  and  some  fluid 
was  discharged.  In  about  a  week  the 
orifice  healed;  a  slight  degree  of  stiffness 
only  remained,  and  he  was  able  to  follow 
his  usual  occupations.  He  continued 
well  till  December,  1810,  when  the  joint 
was  observed  to  be  increased  in  size. 
From  this  time  the  swelling  increased, 
but '  with   no   other   inconvenience   than 


(     78     ) 

stifthess  of  the  joint,  and  a  slight  degree 
of  pain  in  walking. 

At  the  time  of  his  admission  into  the 
hospital,  there  was  a  large  swelling  of 
the  knee,  extending  an  inch  or  more  up 
the  anterior  part  of  the  thigh,  under 
the  extensor  muscles.  The  swelling 
was  more  prominent  in  some  parts, 
than  in  others.  It  was  soft  and  elastic, 
and  g^ve  to  the  hand  an  indistinct  sensa- 
tion, as  if  it  contained  fluid.  The  leg 
w  as  kept  in  a  half-bent  position,  and  was 
nearly  immoveable  on  the  thigh.  He  had 
no  pain,  except  on  motion  or  pressure. 

On  the  28th  of  November,  an  abscess 
burst  on  the  outside  of  the  joint,  and  dis- 
charged a  small  quantity  of  pus.  After 
this  other  abscesses  formed,  and  burst  at 
various  times.  The  swelling  continued 
to  increase.  Amputation  was  performed 
on  the  6th  of  April. 

On  dissecting  the  amputated  joint,  all 
the  ligaments  were  found  in  a  natural 
state.     The  synovial  membrane  had  pre- 


(     79     ) 

(fisely  the  same  appearance  as  in  the  last 
case.  In  some  parts  it  was  half  an  inch, 
in  others  more  than  an  inch  in  thickness. 
The  cartilages  were  for  the  most  part 
destroyed  by  ulceration,  and  ^carious 
surfaces  of  bone  were  exposed.  The  ab- 
scesses appeared  to  have  formed  in  the 
substance  of  the  synovial  membrane,  and 
did  not  communicate  with  the  cavity  of 
the  joint,  nor  did  the  joint  contain  pus. 

CASE  XVI. 

A  boy,  six  years  of  age,  was  admitted 
into  St.  George's  Hospital,  in  March, 
1808,  on  account  of  a  disease  in  one 
knee. 


*  In  using  the  term  caries  on  this  and  on  other 
occasions,  I  have  considered  it  as  synonimous  with 
ulceration;  or,  at  least,  as  expressing  that  state  in 
bones,  which  corresponds  to  ulceration  in  soft  parts. 
Some  confusion  has  been  produced  in  pathological 
nomenclature  in  consequence  of  this  term  having 
been  employed  by  some,  to  express,  not  only  bone, 
which  is  ulcerated,  but  that  whose  surface  has  been 
exposed  from  other  causes. 


(     80     ) 

The  joint  was  larger  than  the  natural 
size.  The  leg  was  bent  at  a  right  angle 
to  the  thigh,  and  admitted  of  no  motion. 
The  skin  on  the  outside  was  ulcerated  to 
a  considerable  extent.  Various  remedies 
having  been  employed  without  success, 
the  limb  was  amputated  on  the  29th  of 
April.  On  examining  the  joint,  the  sy- 
novial membrane  was  found  to  have 
undergone  a  morbid  change  of  structure 
similar  to  that  in  the  preceding  cases, 
but  with  this  difterence,  that  the  pulpy 
substance  into  which  it  was  converted, 
projected  into  the  joint,  so  as  nearly  to 
fill  its  cavity,  and  adhered  to  the  carti- 
laginous surfaces.  On  making  a  longi- 
tudinal section  of  the  joint,  the  cartilage 
covering  the  bones  was  seen,  as  a  white 
line,  about  one-tenth  of  an  inch  in  thick- 
ness, connected  to  the  bone  on  one  side, 
and  having  the  pulpy  substance  adhering 
to  it  on  the  other.  It  was,  therefore, 
thinner  than  natural;  but  otherwise  en- 
tire, except  at  the  posterior  part  of  one 


(     8i      ) 

of  the  condyles  of  the  femur;  where  it 
was  destroyed  hy  iilceriition  for  a  small 
extent.  There  were  no  distmct  remains 
of  the  ligaments  external  to  the  joint, 
and  only  some  small  vestiges  of  the 
crucial  ligaments  and  semilunar  carti- 
lages. 

CASEXVIL 

John  Dillemore,  thirteen  years  of  age, 
was  admitted  into  St,  George's  Hospital, 
in  the  summer  of  181 2,  on  account  of  a 
disease  in  one  knee.  At  that  time  the 
joint  was  slightly  swollen  and  stiff,  so  as 
to  admit  of  only  a  very  limited  degree  of 
motion.  He  was  free  from  pain.  The 
swelling  was  elastic,  without  any  percepti- 
ble fluctuation  of  fluid.  These  symptoms 
had  been  coming  on  gradually  about  two 
years  previous  to  his  admission.  At  this 
time  he  remained  in  the  hospital  for  up- 
wards of  three  months;  and  a  great  num- 
ber of  remedies,  which  it  is  unnecessary 
12 


(      82      ) 

to  enumerate,  were  employed  witliout  the 
smallest  benefit. 

On  the  26th  of  January,  1814,  he  was 
re-admitted  into  the  hospital.  The  af- 
fected knee  was  about  two  inches  and  a 
half  in  circumference  more  than  the 
other.  The  swelling  was  elastic;  it  ex- 
tended up  the  anterior  and  lower  part  of 
the  tliigh,  as  in  cases  of  inflamed  synovial 
membrane,  but  its  form  was  less  regular, 
being  more  prominent,  and  extending 
higher  up  on  the  outside  than  on  the  in- 
side. The  leg  was  kept  in  the  half-bent 
position,  and  was  perfectly  immoveable 
on  tiie  thigh.  He  was  subject  to  occa- 
sional attacks  of  violent  pain.  He  said, 
that  the  swelling  had  gradually  increased 
from  the  period  of  his  quitting  the  hos- 
pital in  1812,  but  that  he  had  not  been 
subject  to  very  severe  pain,  till  about  six 
weeks  previous  to  his  re-admission.  On 
the  31st  of  January  the  limb  was  am- 
putated. 


■(      88      ) 

On  examining  the  diseased  joint,  the 
synovial  membrane  was  found  converted 
into  a  pulpy  substance  of  a  light  brown 
colour,  with  red  spots  arising  from  ves- 
sels ramifying  in  it,  injected  with  'their 
own  blood,  and  intersected  by  very  nu- 
merous membranous  lines.  On  the  out- 
side of  the  joint,  the  diseased  membrane 
was  in  some  places  nearly  an  inch  in 
thickness.  The  membrane  covering  the 
cartilages  in  some  parts  was  in  a  natural 
state;  in  other  parts,  it  had  undergone 
the  same  morbid  change  of  structure  as 
elsewhere.  The  cartilages  were  ulcerated 
in  spots.  TJiere  was  about  half  an  ounce 
of  pus  in  the  cavity  of  the  joint;  and 
there  were  two  or  three  abscesses  in  the 
substance  of  the  synovial  membrane,  not 
communicating  with  the  joint,  contain- 
ing about  the  same  quantity  of  purulent 
matter. 


(      84      ) 

CASE  XYIII. 

AYiliiam  Hine.  twenty-three  years  of 
age,  was  admitted  into  St.  George's  Hos- 
pital on  the  12th  of  December,  1814,  on 
account  of  a  complaint  in  one  of  his 
knees.  He  said,  that  in  the  summer  of 
1812,  he  first  observed  a  slight  degree 
of  stiffness  and  swelling  of  the  joint,  un- 
attended by  pain.  At  first  the  swelling 
was  confined  to  the  inside,  but  it  gradu- 
ally extended  itself  over  the  whole  cir- 
cumference of  the  joint.  The  stiffness 
and  swelling  slowly,  but  uniformly,  in- 
creased: about  the  end  of  the  year  1813, 
he  first  began  to  experience  considerable 
pain. 

At  the  time  of  liis  admission,  the 
knee  was  much  swollen;  the  swelling  was 
irregular  and  most  prominent  on  the 
inside:  it  was  soft  and  elastic,  without 
the  fluctuation  of  fluid.  He  complained 
of  constant,  deep-seated,  gnawing  pain, 
which   disturbed  his   sleep.      He   had   a 


(     85     ) 

^ilight  degree  of  hectic  fever.  On  the 
16th  of  December  the  hmb  was  am- 
putated. 

On  dissecting  the  amputated  joint,  the 
synovial  membrcine  was  found  to  have 
underscone  the  same  morbid  alteration  of 
structure  as  in  the  last  case.  The  car- 
tilages were  slightly  ulcerated  in  a  few 
spots. 

CASE  XIX. 

James  Gould,  sixty-five  years  of  age, 
wa^  admitted  into  St.  George's  Hospital, 
in  3Iay,  1814.  One  knee  was  swollen  and 
stiff,  admitting  of  scarcely  any  motion. 
The  swelling  ^ras  elastic.  He  complained 
of  severe  pain  in  the  joint,  ^ear  the  liga- 
ment of  the  patella  was  the  orifice  of  a 
sinus,  communicating  Avith  the  articular 
cavity,  and  discharging  a  very  small  quan- 
tity of  pus.  No  clear  history  could  be 
procured  of  the  disease  in  its  earlier  stages, 
but  it  appeared,  that  he  had  been  subject 


(      86      ) 

to  repeated  attacks  of  inflammation  of  the 
synovial  membrane. 

The  limb  was  amputated  on  the  23d  of 
May. 

On  dissection,  the  ligaments,  bones, 
cartilages,  and  that  portion  of  the  syno- 
vial membrane  which  is  reflected  over  the 
cartilages,  were  found  to  be  in  a  natural 
state;  but  the  svnovial  membrane  in 
other  parts  had  undergone  the  same  mor- 
bid alteration  of  structure  as  in  the  pre- 
ceding cases. 


These  cases  furnish  examples  of  the 
same  disease  in  different  stages  of  its  pro- 
gress. The  morbid  action  evidently  ori- 
ginates in  the  synovial  membrane,  which 
loses  its  natural  organization,  and  be- 
comes converted  into  a  thick  pulpy  sub- 
stance, of  a  light  brown,  and  sometimes, 
of  a  reddish-brown  colour,  intersected  by 
white  membranous  lines.  As  the  disease 
advances  it  involves  all  the  parts,  of  which 


(     87      ) 

the  joint  is  composed,  producing  iilniev" 
ation  of  tlie  cartilages,  caries  of  the  bones, 
wasting  of  the  ligaments,  and  abscesses  in 
different  places. 

I  have  already  remarked,  that  this  dis- 
ease is  peculiar  to  the  synovial  mem- 
branes; at  least  that  I  have  never  met 
with  it,  in  any  other  part  of  the  body: 
but  it  belongs  to  the  same  order  with 
tubercles  of  the  lungs,  scirrhus  of  the 
breast,  the  medullery  sarcoma  or  fungus 
hsematodes  of  the  testicle,  and  numerous 
others,  in  which  the  natural  structure  of 
the  affected  organ  is  destroyed,  and  a 
new  and  different  structure  is  added  in 
its  place.  To  these  also  it  bears  a  near 
resemblance  in  its  progress.  Thus,  tu- 
bercles of  the  lungs  in  the  first  instance, 
occupy  the  vesicular  and  interlobular  sub- 
stance; but  ultimately,  they  inflame  and 
ulcerate;  abscesses  form  in  them,  and 
then  the  pleura,  the  bronchia,  and  other 
contiguous  parts  become  affected.  Si- 
milar circumstances  mark  the  progress 


(     88     ) 

of    other    maladies    of    tlie     same    de- 
scription. 

The  cases,  which  have  heen  related  are 
not  the  only  ones,  in  which  I  have  had 
the  opportunity  of  tracing  the  same  mor- 
hid  appearances.  I  have  also  met  with 
numerous  others,  in  which  the  similarity 
of  the  history  and  symptoms,  and  the 
resemblance  in  the  form  and  elasticity  of 
the  tumor,  indicated  the  disease  to  be  of 
the  same  nature,  although  I  was  not  able 
to  verify  the  fact  by  dissection.  In  every 
case,  in  which  I  have  had  it  in  my  power 
to  watch  its  progress,  the  complaint  has 
been  slow,  and  sometimes  has  remained 
in  an  indolent  state,  during  a  very  long 
period:  but  ultimately  it  has  alv»^ays 
terminated  in  the  destruction  of  the 
joint. 

It  is  a  remarkable  circumstance,  that 
this  affection  of  the  synovial  membrane 
IS  rarely  met  with  except  in  the  knee.  I 
have  never  known  an  instance  of  it  in 
the  hip  or  shoulder.     It  is  probable  that 


(      89      ) 

the  influence  of  the  external  cold  may 
operate  as  one  of  the  causes,  by  which 
the  disease  is  produced,  and  this  ex- 
plains, why  it  occurs  frequently  in  the 
knee,  and  seldom  in  the  deep-seated 
articulations.* 

It  is  evident  from  the  history  of  cases, 
in  which  a  part  of  the  living  body  has  asr 
sumed  a  new  and  morbid  structure,  that 
this  alteration  seldom  takes  place  except 
by  slow  degrees;  and  it  would  add  much 
to  the  interest  and  utility  of  researches 
in  morbid  anatomy,  if  it  were  more  fre- 
quently attempted  to   ascertain,  what  is 

*  The  account  of  the  fung'us  articuh  which  has 
been  given  by  some  German  writers,  appears  to  have 
been  drawn,  partly  from  cases  of  the  disease  de- 
scribed in  this  chapter,  partly,  from  cases  of  inflam- 
mation of  the  synovial  membrane.  Mr.Russel  seems 
to  have  taken  his  history  of  the  pathology  of  white 
Eweliing,  in  great  measure  from  cases  similar  to  those 
which  have  been  related;  but  we  must  observe,  that 
the  term  white-swelling  has  been  applied,  almost  in- 
discriminately; to  all  the  aftcctions,  to  which  the  joints 
are  liable,  and  by  no  means  confmed  to  that  under 
our  present  consideration. 

13 


(      90      ) 

the  first  change  in  the  organization  of  the 
aftected  part,  which  disease  produces,  and 
from  thence  to  trace  the  gradual  progress 
of  the  other  changes,  which  take  place, 
until  the  destruction  of  the  natural  or- 
ganization is  completed.  Whether  the 
following  case  is  to  be  considered  as  of 
the  same  kind  with  those  already  re- 
corded, but  in  an  earlier  stage  of  the 
disease,  cannot  at  present  be  determined; 
but  it  appears  not  improbable  that  it  is 
so,  and  I  shall  venture  to  relate  it  in 
this  place,  in  the  expectation,  that  it 
may  at  any  rate,  be  of  some  service  in 
assisting  the  investigations  of  future 
inquirers. 

CASE  XX. 
Belton,  a  boy  eleven  years  of  age, 


was  admitted  into  St.  George's  Hospital 
in  August,  1810,  on  account  of  a  disease 
in  one  knee. 

There  was  but  little  pain  in  the  joint: 


(     91      ) 

it  was  slightly  enlarged,  admitted  of  some 
motion,  but  not  of  complete  flexion  and 
extension.  His  parents  said  that  the  dis- 
ease had  begun  about  a  year  and  a  half 
before  his  admission  into  the  hospital: 
that  it  had  increased  very  slowly,  and 
that  he  had  never  suifered  from  it  any 
serious  distress.  Various  remedies  were 
employed  without  benefit;  and  in  a  short 
time  his  friends  took  him  out  of  the  hos- 
pital. A  few  weeks  afterwards  he  died, 
in  consequence  of  an  accumulation  of 
water  in  the  ventricles  of  the  brain. 

I  obtained  permission  to  examine  the 
body. 

The  synovial  membrane  of  the  affected 
knee  externally  had  its  natural  appear- 
ance. Internally  it  was  lined  by  a  straw- 
coloured  gelatinous  substance,  so  inti- 
mately adhering  to  it,  that  it  could  not 
be  detached,  except  by  an  artificial  sepa- 
ration. The  synovial  membrane  was 
encrusted  in  this  manner,  every  where, 
except     on    the    cartilaginous    surfaces. 


(      92       ) 

The  gehitinoiis  substance  in  general  ap- 
peared about  one-eightli  of  an  inch  in 
thickness,  but  in  some  parts  near  the 
borders  of  the  cartilages,  it  was  much 
thicker,  so  as  to  project  considerably 
into  the  cavity  of  the  joint.  In  a  few 
places,  towards  the  margin  of  the  articu- 
lating surfaces,  the  cartilage  had  begun 
to  ulcerate:  in  some  of  these  it  Mas  en- 
tirely absorbed;  so  that  the  bone  was 
exposed;  but,  for  the  most  part,  there 
was  only  an  irregular  ulcerated  surface 
towards  the  cavity  of  the  joint:  the  re- 
maining portion  of  the  cartilage  being 
entire,  and  having  its  natural  adhesion 
to  the  bone. 

The  synovial  membrane  itself  boi-e  no 
marks  of  inflammation.  In  the  substance 
with  which  it  was  lined,  some  vessels 
were  observed  i*amifyiug,  beautifull}^  in- 
jected with  their  own  blood,  but  these 
were  few  in  number,  and  only  in  certain 
parts.  This  substance  differed  in  ap- 
pearance,  from    the    coagulable    lymph. 


(      9-^      ) 

wliich  is  found  on  the  surface  of  an  in^ 
flamed  membrauc;  and  we  may  presume, 
therefore,  that  the  effusion  of  it  was  the 
result,  not  of  inflammation,  hut  of  some 
other  mor])id  action. 


Sect.  IT. 
On  the  Symptoms  of  this  Disease. 

This  disease  generally  takes  place  in 
persons,  who  are  not  much  above  the  age 
of  puberty.  I  do  not  recollect  more  than 
one  instance  of  it  having  occurred  after 
the  middle  period  of  life.  In  general  it 
can  be  traced  to  no  evident  cause,  but  oc- 
casionally it  takes  place  in  consequence  of 
repeated  attacks  of  inflammation.  In  this 
respect  it  resembles  other  diseases  of  the 
same  order.  Inflammation  of  the  lungs 
may  lay  the  foundation  of  tubercles,  and 
inflammation  of  the  breast  may  occasion 
the  growth  of  a  scirrhous  tumor.  Where 
I  have  had  an  opportunity  of  examining 


(     94     ) 

the  morbid  appearances  after  aniputatioDj 
I  have  always  found  the  whole,  or  nearly 
the  whole,  of  the  synovial  membrane 
afl'ected  by  the  disease;  but  it  is  pro- 
bable, that  if  the  examinations  were  made 
at  an  earlier  period,  we  should  often  find 
the  morbid  change  originating  in  some 
one  point.  At  least  this  is  in  conformity 
to  what  we  find  in  other  maladies,  which 
correspond  to  this  in  their  nature:  and  in 
one  instance,  in  a  girl  who  laboured  under 
this  affection,  and  who  died  of  a  fever, 
I  found  one  half  of  the  synovial  mem^ 
brane  altered  in  structure,  and  the  other 
half  retaining  its  natural  appearance. 

In  the  origin  of  this  disease,  there  is 
a  slight  degree  of  stiffness  and  tume- 
faction, without  pain,  and  producing  only 
the  most  trifling  inconvenience.  These 
symptoms  gradually  increase,  hi  the 
greater  number  of  cases,  the  joint  at  last 
scarcely  admits  of  the  smallest  motion, 
but  in  a  few  cases,  it  always  retains  a 
certain  degree  of  mobility.     The  form  of 


(     95     ) 

the  swelling  bears  some  resemblance  to 
that  in  cases  of  inflammation  of  the  sy- 
novial membrane,  but  it  is  less  regular. 
The  swelling  is  soft  and  elastic,  and  gives 
to  the  hand  a  sensation  as  if  it  contained 
fluid.  If  only  one  hand  be  employed  in 
making  the  examination,  the  deception 
may  be  complete,  and  the  most  ex- 
perienced surgeon  may  be  led  to  suppose 
that  there  is  fluid  in  the  joint,  when 
there  is  none:  but  if  both  hands  be  em- 
ployed, one  on  each  side,  the  absence  of 
fluid  is  distinguished  by  the  want  of 
fluctuation. 

The  patient  experiences  little  or  no 
pain,  until  abscesses  begin  to  form,  and 
the  cartilages  ulcerate;  and  even  then 
the  pain  is  in  many  instances  not  so 
severe,  as  where  the  ulceration  of  the  car- 
tilages occurs  as  a  primary  disease:  and 
the  abscesses  heal  more  readily,  and  dis- 
charge a  smaller  quantity  of  pus,  than  in 
cases  of  this  last  description.  At  this 
period  the  patient  becomes  affected  with 


(      96      ) 

hectic  fever;  loses  his  flesh,  and  gra- 
dually sinks,  unless  the  limb  be  removed 
by  an  operation. 

The  progress  of  this  disease  varies  in 
different  cases.  In  general,  one  or  two 
years  elapse  before  it  reaches  its  most 
advanced  stage;  but  sometimes  the  period 
is  much  longer;  and  occasionally  it  be- 
comes indolent,  so  that  it  remains  during 
many  months  without  any  sensible  alter- 
ation. In  like  manner  tubercles  of  the 
lungs,  or  scirrhus  of  the  breast,  in  some 
instances  remain  in  an  inactive  state  for 
several  months,  or  even  for  one  or  two 
Years. 

The  diagnosis  of  this  disease  is  seldom 
difficult.  The  gradual  progress  of  the 
enlargement,  and  stiffness  of  the  joint 
without  pain,  and  the  soft  elastic  swelling 
without  fluctuation,  in  the  majority  of 
cases  enable  us  to  distinguish  it  readily 
from  all  the  other  morbid  affections  to 
which  the  joints  are  liable. 

The  cases,  with  which  those  of  this 


(    ^^    ) 

<liseaso  iii'e  most  liable  to  be  confounded, 
fire  those  of  chronic  inflammation  of  the 
synovial  membrane. 

1st,  When  the  synovial  membrane  has 
undergone  a  morbid  change  of  structure, 
it  occasionally  happens  that  a  preternatural 
secretion  of  fluid  takes  place  at  the  same 
time  from  its  inner  surface;  and  the  joint 
])ecomes  distended,  not  with  synovia,  but 
with  a  turbid  serum  having  flakes  of  co- 
agulable  lympb  floating  in  it,  which  causes 
the  tumor  to  present  nearl}^  the  same  ex- 
ternal characters,  as  where  the  synovial 
membrane  is  inflamed.  But  here  the 
swelling  will  not  yield  to  that  treatment, 
under  which  it  would  be  speedily  reduced 
t^\  depended  on  simple  inflammation; 
aiul  attention  to  tliis  circumstance,  joined 
with  an  accurate  previous  historj^,  will 
enable  us  to  recognise  the  real  nature  of 
the  disease. 

2dly,    When  the    synovial   membrane 
after  inflammation  has  subsided  has  been 
left  in  a  thickened  state,  and  coagulable 
11 


(      08      ) 

lymph  liJis  been  effused  into  the  artieular 
cavity,  the  tumor  in  some  instances  a  good 
deal  resembles  the  tumor.  ^  hich  occurs  in 
cases  of  this  disease:  so  much  so,  that  it 
will  be  very  difficult  to  give  a  correct  opi- 
nion, merely  from  observing  the  present 
appearance  and  condition  of  the  joint. 
The  surgeon  must  in  great  measure  form 
his  judgment  from  the  account;  which  he 
receives  of  the  origin  and  early  symp- 
toms of  the  complaint;  or  (when  an 
accurate  statement  cannot  be  procured) 
by  waiting  to  observe  its  future  progress. 


Sect.  III. 

On  the  Treatment. 

When  a  part  is  swollen  and  rigid  in 
consequence  of  inflammation,  the  swell- 
ing and  rigidity  may  often  be  dispersed; 
but  I  know  of  no  instance,  in  which  an 
organ  having  completely  lost  its  natural 
structure,  is  capable  of  having  that  struc- 
ture restored.     Physicians  and  surgeons 


(      99      ) 

hnve  been  employed  during  successive 
ages,  in  endeavouring  to  discover  a  cure 
for  tubercles  of  tbe  lungs,  and  cancer  of 
tbe  breast,  and  tlic  result  of  their  labour 
is  only  to  prove  tbat  those  diseases  are 
incurable.  Analogy  therefore  would  not 
lead  us  to  be  sanguine  as  to  the  discovery 
of  a  remedy  for  this  affection  of  the  synovial 
membrane,  and  experience  shews  that  it 
is  equally  incurable  with  other  maladies  of 
the  same  order.  It  would  be  needless 
for  me  to  occupy  the  time  of  my  readers, 
by  a  detail  of  the  various  remedies,  which 
I  have  tried,  or  seen  tried  by  others,  in 
cases  of  this  descrijition;  since  the  gene- 
ral result  of  these  trials  was  only  to  lead 
to  the  above  conclusion.  By  means  of 
rest  and  cold  lotions,  the  progress  of  the 
disease  may  be  somewhat  checked,  as  the 
suppuration  of  tuberculated  lungs  may  be 
retarded  by  occasional  bleeding,  and  a 
mihler  climate.  Where  there  is  consider- 
able pain  in  conseijuence  of  the  cartilages 
having  begun  to  ulcerate,  some  benefit  is 


(      100      ) 

derived  from  the  use  of  warm  foment- 
ations and  poultices.  But  no  method^ 
with  which  I  am  acquainted,  is  capahleof 
doing  more  than  somewhat  checking  the 
progress,  and  somewhat  relieving  the 
symptoms  of  the  complaint.  In  every 
case,  of  which  I  liave  had  an  opportunity 
of  seeing  the  termination,  the  ulceration 
of  the  cartilages,  the  formation  of  ah- 
scesses  in  the  cavity  of  the  joint,  and  the 
consequent  disturhance  of  the  patient's 
general  health,  have  ultimately  rendered 
the  amputation  of  the  limh  necessary,  in 
order  to  perserve  the  patient's  life.  At 
this  period  therefore  the  surgeon  is  called 
upon  to  recommend  and  urge  an  oper- 
ation: but  at  an  earlier  period,  it  is  a 
matter  of  choice  with  the  patient,  whether 
he  will  live  with  the  incumbrance  of  an 
useless  limb,  till  the  advanced  stage  of  the 
disease  renders  its  removal  indispensable 
or  whether  he  will  submit  to  the  loss  of 
it,  before  the  absolute  necessity  for  losing 
it  exists. 


CHAP.  IV. 

'>N  THE  ULCERATION  OF  THE  CARTILAGES 
OF  JOINTS. 


Sect.  I. 
Pathological  Observations. 

The  cartilages  of  joints  differ  in  some 
^^ssential  circumstances  from  those,  wliich 
are  employed  in  other  organs.  The  lat- 
ter are  more  vascular,  more  liahle  to  be- 
come inflamed;  and  inflammation  in 
them  usually  terminates  in  the  depo- 
sition of  osseous  matter.  The  articular 
cartilages  in  the  adult  possess  no  vessels 
capable  of  carrying  red  blood-  Inflamma- 
tion is  not  in  them  a  frequent  occurrence; 
when  it  does  take  place,  it  terminates 
m  ulceration,  and  not  in  the  formation 
jfbone.  Ulceration  of  cartilage  may  be 
ihe  consequence  of  inflammation  of  the 


(      102      ) 

fcurtilagc  itself,  or  of  the  bony  surface,  to. 
which  it  is  connected;  but  in  many  in- 
stances there  are  no  evident  marks  of 
inflammatory  action  having  preceded  it, 
either  in  one  part  or  the  other,  and  the  in- 
flammation, Avhicli  aftei'wards  takes  place 
appears  to  be  rather  the  attendant  on, 
than  the  cause  of,  the  ulcerative  process. 
The  ulceration  of  soft  parts  is  usually, 
and,  as  far  as  I  know,  always  attended 
with  the  secretion  of  pus;  but  it  is  other- 
wise with  the  articular  cartilages,  in  which 
suppuration  seldom  takes  place,  while 
the  ulcer  is  small,  and  often  the  disease 
proceeds  so  far,  as  to  cause  caries  of  the 
bones  to  a  considerable  extent,  without 
matter  being  formed  in  the  joint.  This 
circumstance  is  deserving  of  notice.  It 
has  been  long  established  that  suppur- 
ation may  take  place  without  ulceration; 
and  it  appears,  that,  in  this  instance,  ulcer- 
ation may  take  place  without  the  form- 
ation of  pus. 

In  the  cases,  which  have  been  related, 


(     *03     ) 

the  ulceration  of  the  cartilages  of  the  clis^ 
eased  joints  was  a  secondary  affection,  the 
consequence  of  a  niorl)id  action  originat- 
ing in  the  neighbouring  soft  parts.  There 
are  other  cases^  and  tliose  not  of  rare 
occurrence,  in  which  the  ulceration  of 
the  articular  fartilages  exists  as  a  primary 
disease. 

When  the  nlceration  of  the  cartilage 
■occurs  in  the  snperficial  joints,  it  con^ 
stitutes  one  of  the  diseases,  which  have 
been  known  by  tlie  name  of  white-SAvel- 
lins:.  From  cases  which  I  have  met 
with,  I  am  led  to  conclude,  that  when  it 
takes  phice  in  the  hip,  it  is  this  disease, 
which  has  l)een  variously  designated  by 
writers,  the  "  Morbus  Coxarius,"  the 
^'  Disease  of  the  Hip,"  the  "  Scrophulons 
Hip,"  the  "  Scroplmlous  Caries  of  the 
Hip-joint."  At  least  it  is  to  this  disease, 
that  these  names  have  been  principally 
applied,  though  probably,  other  morbid 
affections  have  been  occasionally  con- 
founded with  it. 


(   1^1  ) 

CASE  XXI. 

In  examining  a  body,  brought  into 
tbe  dissecting-room  in  Windmill-street,  I 
found  tbe  cartilage  in  a  diseased  state,  in 
tbe  joints  of  botb  bips,  of  one  of  tbe 
knees,  and  of  botb  elbows.  In  some 
spots,  tbe  cartilages  of  tbese  joints  were 
altogetber  destroyed  by  ulceration,  and 
carious  surfaces  of  bone  were  exposed; 
in  otbers,  tbe  cartilage  was  not  com- 
pletely absorbed,  but  it  bad  tbe  appear- 
ance of  fibres,  Avbicb  w  ere  connected  at 
one  extremity  to  tbe  bone,  w  bile  the  otber 
extremity  was  loose  towards  tbe  cavity  of 
tbe  joint,  and  baving  no  lateral  connec-' 
tion  witb  eacb  otber.  Tbe  intervertebral 
cartilages  connecting  tbe  bodies  of  some 
of  tbe  dorsal  vertebrae  were  also  in  a  dis-^ 
eased  state*  Tbey  retained  tbe  usual 
appearance  of  concentric  layers  towards 
tbe  circumference,  but  in  tbe  centre,  in- 
stead of  tbe  wbite  semi-fluid  substance, 
wbicb  is    met   witb   under  ordinary  cir- 


(      105      ) 

rii  111  stances,  they  were  found  to  be  of  a 
brown  colour,  of  a  solid  and  somewhat 
brittle  texture,  composed  of  several  por- 
tions, haying  a  very  slight  adhesion  to 
each  other.  The  ligaments,  the  synovial 
membranes,  and  the  bones,  were  all  in  a 
natural  state,  except  that  the  latter  were 
occasionally  carious  in  consequence  of 
the  absorption  of  the  cartilage;  but  the 
caries  was  unattended  bv   the  formation 

ft' 

of  matter. 

In  this  case,  the  original  disease  appears 
to  have  been  a  morbid  state,  and  subset 
quent  ulceration  of  the  cartilages.  It 
shews  that  where  the  disposition  to  it 
exists,  the  destruction  of  the  cartilage 
may  take  place  in  several  joints  at  the 
same  time,  and  I  have  observed  the  same 
thing  in  many  other  instances. 

The  conversion  of  the  cartilage  into  a 
soft  fibrous  structure,  I  am  disposed  to 
believe,  is  the  frequent,  though  not  the 
constant  forerunner  of  ulceration.  In  a 
woman,  who  died  a  week  after  a  severe 

15 


(^      106      ) 

contusion  of  tlie  hip,  the  cartilage  of  the 
head  of  the  femur  Avas  found  in  some 
parts  entirely  absorhed,  in  others  having 
a  fibrous  appearance,  similar  to  what  has 
been  described,  and  I  have  noticed  the 
same  cu'cumstance  in  other  cases,  some- 
times connected  with,  and  sometimes  in- 
dependent of  local  injury. 

CASE  XXII. 

A  boy,  ten  years  of  age,  was  admitted 
into  St.  George's  Hospital,  in  April  1809, 
on  account  of  a  disease  of  the  left  hip. 
The  nates  were  wasted,  and  flattened; 
there  was  pain  in  the  hip  and  knee,  and 
a  large  abscess  had  formed  which  pro- 
duced a  tumor  on  the  outside  of  the 
thigh.  An  issue  was  made  with  caustic 
behind  the  great  trochanter.  About  a 
month  after  his  admission,  the  skin  over 
the  abscess  having  become  inflamed,  I 
made  an  opening  in  it,  with  a  lancet,  and 
half  a  pint  of  pus  was  evacuated.     The 


(      107      ) 

orifice  made  by  the  lancet,  healed  by  the 
first  intentian,  but  in  a  few  days,  pus  was 
again  collected  in  the  abscess,  and  the 
tumor  was  larger  and  more  tense  than 
ever.  The  limb  became  shortened,  the 
abscess  burst  externally,  the  boy  became 
affected  with  hectic  symptoms,  and  died 
on  the  21st  of  October. 

On  examining  the  body,  the  abscess  was 
found  communicating  with  the  cayity  of 
the  left  hip.  The  capsular  ligament  and 
synovial  membrane  were  not  distinguish- 
able from  the  other  soft  parts,  forming 
the  pariet.es  of  the  abscess.  There  was  no 
vestige  of  the  round  ligament,  and  no 
remains  of  cartilage  on  either  of  the  bones 
composing  the  joint.  The  head  of  the 
femur  was  reduced  by  caries,  to  about 
one  half  of  its  natural  size;  and  from  the 
same  cause,  the  acetabulum  was  rendered 
deeper  and  wider  than  is  natural.  At 
the  posterior  part,  the  margin  of  the 
acetabulum  was  more  extensively  ab- 
sorbed, and  the  head  of  the  femur  had 


(      108      ) 

been   drawn    out  of  its   ca\it},   and    was 
lodged  on  the  dorsum  of  the  ilium. 

"No  other  disease  had  been  suspected 
to  exist  during  life.  If  the  boy  had  ever 
complained  of  pain  in  the  right  hip,  the 
circumstance  had  been  overlooked,  on  ac- 
count of  the  greater  disease  in  that  of  the 
opposite  side.  Having  accidentall}'  cut 
into  the  joint  of  the  right  hip,  I  found 
the  cartilage  covering  the  head  of  the 
femur,  absorbed  for  about  one-third  of 
its  extent,  and  the  surface  of  bone,  which 
was  in  consequence  exposed,  w^as  covered 
by  a  thin  layer  of  coagulable  lymph.  The 
cartilage  lining  the  acetabulum,  and  all 
the  soft  parts  belonging  to  the  joint, 
were  in  a  perfectly  natural  state,  and  the 
bones  wel'e  of  the  ordinary  texture  and 
hardness. 


CASE  XXIII. 


A.  girl,  seven  years  of  age,  was  adniitteci 
into    St.     George's     Hospital,     in     3Jay, 


(      109      ) 

1809,  on  account  of  a  complaint  in  thfe 
left  hip.  She  had  pain  in  the  knee,  the 
limb  was  shorter  than  is  natural,  and  the 
nates  were  wasted  and  flattened.  An 
issue  was  made  with  caustic,  behind  the 
gi'eat  trochanter.  Soon  after  her  admis- 
sion an  abscess  burst  near  the  crista  of  the 
ilium.  The  disease  in  the  hip  appeared 
to  be  considerably  relieved,  but  on  the 
first  of  August,  she  died  of  an  accidental 
attack  of  erysipelas. 

On  inspecting  the  body,  the  glutaei 
muscles  of  the  left  side  were  found  wast- 
ed and  of  a  dark  colour.  A  sinus  extended 
from  the  external  orifice  of  the  abscess 
through  the  soft  parts,  and  communicated 
with  the  hip-joint,  by  an  ulcerated  open- 
insf  in  the  margin  of  the  acetabulum. 

There  were  no  remains  of  cartilage  on 
the  surface  of  the  acetabulum.  The  ex- 
posed bone  was  in  a  carious  state,  and 
of  a  dark  colour,  and  the  cavity  of  the 
ai^etabulum  was  rendered  deeper  and 
wider  tlian  is  usual.  The  greater  part  of 
the  cartilage  was  destroyed  on  the  head 


(     *io    > 

of  the  femur,  and  the  small  portion  of  it 
which  remained,  was  readily  separated 
from  the  hone.  This  circumstance  is 
often  met  with,  where  cartilage  is  under- 
going the  process  of  ulceration. 

The  capsular  ligament  was  somewhat 
thicker  than  under  natural  circumstances, 
and  more  connected  with  the  surrounding 
parts.  There  were  no  remains  of  the 
round  ligament. 

In  tlie  anterior  part  of  the  joint,  a 
quantity  of  organised  soft  substance,  re- 
sembling that  of  adhesions,  was  interpo- 
sed between  the  head  of  the  femur  and 
the  acetabulum,  and  behind  this  was  a 
collection  of  dark-coloured  pus.  From 
these  two  causes  the  head  of  the  femur 
had  been  separated  from  the  os  innomi- 
natum,  and  pushed  outwards,  and  it  had 
afterwards  been  drawn  upwards  by  the 
action  of  the  muscles,  so  that  it  was 
lodged  on  the  superior  part  of  the  bony 
margin  of  the  acetabulum.  The  synovial 
membrane  was  of  a  dark  colour,  but  not 
otherwise  diseased. 


(  111  ) 

On  examining  the  liip  of  the  opposite 
^ide,  I  found  the  soft  parts  external  to  it, 
the  capsular  ligament,  synovial  mem- 
brane, and  fatty  substance  of  the  joint, 
having  no  appearance  of  disease.  The 
cavity  of  the  joint  contained  about  a 
drachm  of  dark-coloured  pus.  The  car- 
tilao'e  was  absorbed  from  about  one-third 
of  the  surface  of  the  acetabulum.  The 
exposed  bone  in  most  parts  presented 
an  uniform  compact  surface,  but  in  two 
places  it  was  in  a  state  of  superficial 
caries.  In  some  parts  of  the  head  of  the 
femur,  the  cartilage  had  a  fibrous  appear- 
ance, similar  to  what  has  been  already 
described;  in  other  parts  it  was  entirely 
absorbed,  and  a  carious  surface  of  bone 
was  exposed;  and  elsewhere  it  was  in 
a  natural  state.  The  round  ligament 
was  ruptured  by  a  very  slight  degree  of 
force,  which  seemed  to  arise  from  the 
cartilage  having  been  destroyed  round  its 
insertion  into  the  acetabulum. 

The  bones  in  the  neighbourhood  of 
the  carious  surfaces  of  the  left  hip,  were 


(    H2    ) 

of  a  darker  colour  than  usual;  but  no 
such  appearauce  was  observed  in  the 
bones  of  the  other  hip,  which  were  in  all 
respects  in  a  healthy  state. 


CASE  XXI\. 

John  Catnack,  forty-four  years  of  age, 
was  adniitted  into  St.  George's  Hospital 
on  the  29th  of  September,  1813,  with 
pains  in  the  lower  limb  of  the  right  side, 
extending  from  the  hip  to  the  knee,  and 
resembling  the  pains  of  rheumatism. 
He  attributed  these  pains  to  his  having 
caught  cold  about  a  month  before  his 
admission.  He  laboured  also  under  a 
complaint  of  his  bowels,  of  which  he 
died  on  the  4th  of  December.  On  dis- 
section,  no  preternatural  appearances  were 
discovered,  except  in  the  right  hip.  The 
capsular  ligament  and  synovial  membrane 
were  in  a  natural  state.  The  cartilages  co- 
vering the  head  of  the  femur,  and  lining 
the  bottom  of  the   acetabulum,  were   de- 


stroyed  by  ulceration,  for  about  one-balf 
of  their  extent,  and  wherever  the  car- 
tilage was  destroyed,  an  ulcerated  surface 
of  bone  was  exposed.  The  round  liga- 
ment was  readily  torn,  in  consequence 
of  ulceration  having  extended  to  it,  at 
the  part  where  it  was  inserted  into  the 
acetabulum.  The  bones  possessed  their 
natural  texture  and  hardness.  There 
was  no  pus  in  the  joint.  It  was  ob- 
served, that  the  ulcerated  surface  of  the 
acetabulum  corresponded  to  that  of  the 
femur,  these  surfaces  being  exactly  in 
contact,  in  the  position  in  which  the 
patient  had  remained  since  his  admission 
into  the  hospital. 

CASE  XXV. 

William  Bridges,  twenty-one  years  of 
age,  was  admitted  into  St.  George's  Hos- 
pital, on  the  28th  of  November,  1810. 
He  gave  the  following  account  of  his 
complaint.    About  the  middle  of  the  May 

16 


(      114     ) 

preceding,  he  first  experienced  a  pain  in 
the  right  knee,  wliich  was  aggravated  by 
walking.  At  the  end  of  a  month,  the 
pain  became  so  severe  that  he  was  under 
the  necessity  of  being  confined  to  his 
bed.  He  had  slight  pain  in  the  hip^ 
but  that  in  the  knee  was  intense,  keeping 
him  awake  at  night.  An  abscess  formed, 
which  in  the  September  following  burst 
on  the  inside  of  the  thigh. 

At  the  time  of  his  admission,  the  nates 
were  wasted  and  flattened;  the  limb  on  the 
affected  side,  appeared  to  be  an  inch  and 
a  half  louger  than  the  other;  there  was  a 
large  abscess  in  the  posterior  part  of  the 
thigh.  He  was  emaciated,  and  laboured 
under  a  hectic  fever.  An  issue  was  made 
with  caustic,  behind  the  great  trochanter  of 
the  femur,  and  afterwards  a  second  issue 
was  made  in  the  same  manner  on  the  an- 
terior edge  of  the  tensor  vaginae  femoris 
muscle.  Under  this  treatment,  he  experi- 
'cnced  for  a  time  great  relief,  notwithstand- 
ing several  abscesses  formed  and  burst  m 


(      115      ) 

different  parts  of  the  thigh.  He  hecame 
free  from  pain;  regained  his  flesli;  the 
hectic  fever  abated;  and  the  discharge 
from  the  abscesses  was  much  lessened. 
The  limb  now  appeared  to  be  shorter 
than  the  other.  He  continued  to  mend, 
till  the  middle  of  February,  1811.  At 
this  period  the  former  bad  symptoms 
began  to  return.  He  was  affected  with 
a  constant  diarrhoea,  and  profuse  perspi- 
rations, and  he  died  on  the  26th  of  March 
following. 

On  inspecting  the  body,  the  glutsei 
muscles  were  found  wasted  and  shrunk, 
and  in  many  parts  their  texture  was 
destroyed  by  the  abscesses,  which  com- 
municated with  the  cavity  of  the  joint 
by  two  ulcerated  openings,  one  on  the  an- 
terior and  the  other  on  the  posterior  part. 
The  abscesses  formed  several  sinuses  in 
the  neighbourhood  of  the  joint,  and  the 
capsular  ligament  was  in  consequence 
connected  to,  and  in  some  measure  blend- 
ed with  the  other  soft  parts. 


(      116      ) 

The  joint  contained  purulent  matter. 
The  synovial  membrane  was  darker  than 
natural,  but  otherwise  had  the  ordinary 
appearance.     There  were  no  remains  of 
the  round  ligament.     The  cartilages  were 
every  where  absorbed,  and  the  exposed 
surfaces  of  bone  were  in  a  carious  state. 
The  head  of  the  femur  was  reduced  to 
about  two-thirds  of  its  original  size,  and 
the  acetabulum  Avas  rendered  deeper  and 
wider,    nearly  in   the    same   proportion. 
At  the  bottom  of  the  acetabulum,  there 
was    an    ulcerated    opening,    just   lai'ge 
enough  to  admit  a  common  probe,  com- 
municating with  an   abscess  within  the 
pelvis.   The  carious  surfaces  of  the  bones, 
had  the  same  dark  colour  and  foetid  smell, 
as  in  other  cases  of  caries,  but  otherwise 
they  did  not  differ  from  healthy  bones. 

CASE  XXVI. 


Jemima  HoUoway,  about  23  years  of  age, 
was  admitted  into  St.  George's  Hospital 


(      IIT     ) 

on  the  30 til  March,  1814,  on  account  of 
a  disease  of  the  right  hip.  There  was  a 
large  ahscess  in  the  neighhourhood  of  the 
hip,  and  the  nates  were  wasted,  and  flat- 
tened. She  said  that  the  disease  had  been 
going  on  for  some  years.  On  the  6th  of 
June  following  her  admission,  she  died. 

On  dissection,  the  glutsei  muscles  were 
found  wasted  and  flabby,  and  of  a  pale 
colour. 

There  was  a  large  abscess  of  the  nates 
communicating  with  the  hip,  by  means  of 
an  opening  in  the  posterior  part  of  the 
♦capsular  ligament  and  synovial  membrane. 
In  other  respects  the  synovial  membrane 
and  capsular  ligament  were  in  a  perfectly 
natural  state. 

The  cartilages  covering  the  head  of  the 
femur,  and  lining  the  bottom  of  the  ace- 
tabulum were  destroyed  by  ulceration. 
The  ulceration  had  extended  to  the 
bones,  so  that  the  head  of  the  femur  was 
not  more  than  half,  and  the  acetabulum 
was  double  the  usual  size.     The  bones 


(      1<8      ) 

possessed  their  natural  texture  and  hard- 
ness. There  was  an  ulcerated  opening 
at  the  hottom  of  the  acetahulum,  com- 
municating with  the  inside  of  the  pelvis. 


I  could  add  to  tlie  foregoing,  an  ac- 
count of  the  dissection  of  several  other 
cases,  in  which  the  hip  was  affected  with 
the  same  disease;  but  in  doing  so,  I 
should  only  occupy  the  reader's  attention 
unnecessarily.  It  will  he  sufficient  to 
observe  that: 

1.  In  tlie  most  advanced  stage  of  the 
disease,  none  of  the  parts  entering  into 
the  composition  of  the  joint  retain  theii* 
natural  structure.  The  soft  parts  are 
blended  into  a  confused  mass.  Some- 
times the  head  of  the  femur  is  com- 
pletely destroyed,  and  there  remains  only 
the  neck,  or  a  portion  of  the  neck,  of  that 
bone.  Often  the  projecting  margin  of 
the  acetabulum  is  entirely  absorbed,  so 
that  instead  of  a  cavity,  there  is  a  broad 


(      119      ) 

i^nrlous  surface  of  the  os  innonuoatum. 
In  a  feAV  instances  a  portion  of  the  ca- 
rious bone  is  found  dead,  ancl  undergoing 
the  process  of  exfoliation,  or  having  al- 
ready exfoliated  into  the  cavity  of  tliQ 
joint. 

2.  In  whatever  period  of  the  disease, 
tlie  examination  is  made,  the  cartilages 
are  found  in  a  state  of  ulceration,  but  the 
morbid  affections  of  the  soft  parts  and 
bones  vary  very  much,  nor  are  they  muck 
altered  from  their  natural  state,  except 
in  the  most  advanced  stage  of  the  ma- 
lady. 

From  these  circumstances,  and  from 
the  appearances  in  several  of  the  cases 
v.hicli  have  been  related,  in  which  the 
disease  was  found  in  its  incipient  stage, 
and  wholly  confined  to  the  cartilaginous 
surfaces,  we  may  be  justified  in  conclud- 
ing, that,  in  the  ordinary  cases  of  caries 
of  the  hip,  the  cartilage  is  the  part  pri- 
marily aftccted,  and  the  following  may  be 
stilted  to  be  the  progress  of  the  disease. 


(      120      ) 

1.  Ulceration  takes  place  in  the  carti- 
lages: generally  in  that  of  the  acetahu- 
lum  first,  and  in  that  of  the  head  of  the 
femur  afterwards;  sometimes  it  begins  in 
both  at  the  same  time. 

2  The  ulceration  extends  to  the  bones, 
which  become  carious;  the  head  of  the 
femur  is  diminished  in  size,  and  the  ace- 
tabulum is  rendered  deeper  and  wider. 

3.  Abscess  forms  in  the  joint,  which 
after  some  time  makes  its  way,  by  ulcera- 
tion, through  the  synovial  membrane  and 
capsular  ligament,  into  the  thigh,  or  nates, 
or  even  through  the  bottom  of  the  aceta- 
bulum into  the  pelvis.  Mr.  Astley  Cooper 
has  shewn  me  two  specimens,  in  each 
of  which  the  abscess  had  burst  into  the 
rectum. 

4.  In  consequence  of  the  abscess,  the 
synovial  membrane  and  capsular  ligament 
become  inflamed  and  thickened.  The 
muscles  are  altered  in  structure;  sinuses 
are  formed  in  various  parts;  and  at  last 
all   the  soft  parts  are  blended  together 


(      121      ) 

into  one  contused  mass.;  resembling  llic 
pai'ietes  ol*  an  ordinary  al^scess. 

In  giving  tliis  statement,  it  cannot  be 
intended  to  assert,  that  the  hip  is  not 
liable  to  other  morbid  aftections;  and  of 
course,  disease  having  its  origin  in  the 
bones  or  soft  parts  may  ultimately  occa- 
sion destruction  of  the  cartilaginous  sur- 
faces in  this  as  well  as  in  other  joints; 
but  still  the  conclusion  remains,  that  ia 
the  ordinary  disease  of  the  hip  joint,  in 
that  disease,  which  an  intelligent  surgeon, 
in  a  work  written  expressly  on  the  sub- 
ject, has  denominated  "  The  Scrophulous 
Caries  of  the  Hip,"  the  ulceration  of 
the  cartilages  is  the  primary  affection, 
and  the  other  parts,  in,  and  near  the 
joint,  become  aftectcd  only  in  a  secondary 
manner. 

As  from  the  peculiar  situation  and  con- 
nections of  the  hip,  affections  of  this  part 
aic  attended  with  particularly  serious  con- 
Bcqucnces,  I  trust  that  the  lurgoing  ac- 
count, will  not  be  considered  as  given  too 
17 


(      122     )    . 

much  ill  detail,  ^specially  as  it  ^vill  pre* 
rent  the  necessity  of  entering  with  much 
minuteness  into  the  history  of  the  ul- 
ceration of  the  cartilages  of  other  joints, 
in  which  the  progress  of  the  disease,  al- 
lowance being  made  for  the  difference  of 
structure  and  situation,  is  the  same  as  in 
the  hip. 


CASE  XXVII. 

David  Martin,  twenty-six  years  of  age, 
was  admitted  into  St.  George's  Hospital, 
on  the  25th  of  July,  1810,  on  account  of 
a  disease  in  his  right  knee.  He  attributed 
it  to  a  blow,  which  he  had  received  some 
years  previous;  but  he  said,  that  the 
symptoms  had  all  been  much  aggravated 
within  the  last  six  months.  At  the  time 
of  his  admission  into  the  hospital,  the 
knee  had  the  appearance  of  being  sw  oUen; 
but  on  examination,  this  was  found  to 
arise  from  the  w  asting  of  the  muscles,  ra- 
ther than  from  actual  enlargement.     The 


(      123      ) 

lieg  was  fixed,  or  nearly  so,  in  the  lialf-bent 
position.  The  condyles  of  the  femur 
projected  beyond  the  head  of  the  tibia. 
He  complained  of  pain,  which  was  parti- 
cularly severe  at  night.  An  issue  was 
made  with  caustic  on  each  side  of  the 
patella;  but  the  symptoms  were  not  re- 
lieved, and  an  abscess  burst  on  the  out- 
side of  the  joint,  discharging  a  large 
quantity  of  matter. 

Soon  after  his  admission,  he  expe- 
rienced, for  the  first  time,  severe  pain  in 
the  other  knee;  but  this  was  unattended 
by  swelling,  or  any  alteration  in  the  form 
of  the  joint,  and  the  leg  admitted  of  com- 
plete extension  and  flexion  on  the  thigh. 
The  pain  continued,  but  no  swelling  ever 
took  place. 

In  the  beginning  of  September,  he  was 
seized  with  an  accidental  attack  of  ery- 
sipelas. Abscesses  formed  in  different 
parts  of  the  leg  and  thigh;  and  he  gra- 
dually sunk,  and  died  on  the  7th  of  No- 
vember. 


(      12.1      ) 

On  inspecting  the  body,  tlie  right  leg 
was  found  bent  so  as  to  form  a  right  angle 
Avith  the  thigh.  The  head  of  the  tibia 
had  been  drawn  towards  the  ham  by  the 
action  of  the  flexor  muscles,  so  that  the 
condyles  of  the  femur  were  unusually 
protuberant.  The  lateral  ligaments  were 
in  a  natural  state.  There  were  no  remains 
of  the  crucial  ligaments,  or  semilunar 
cartilao:es.  The  cartilages  of  the  tibia, 
femur,  and  patella,  had  been  entirely  ab- 
sorbed. The  bones  were  carious  on  their 
exposed  surfaces,  but  not  otherwise  dis- 
eased. The  synovial  membrane  was  free 
from  all  morbid  appearances,  except  at 
the  points  of  its  attachment  to  the  bones, 
where,  in  a  few  places,  coagulable  lymph 
had  been  effused  on  its  surface. 

The  left  knee,  externally,  had  its  natu- 
ral appearance  with  respect  both  to  form 
and  size.  The  leg  admitted  of  complete 
flexion  and  extension.  On  dissection, 
the  lia:aments  and  synovial  membrane 
were  found  in  a  perfectly  healthy  state; 


(     135     ) 

but  about  one-third  of  the  cartilaginous 
surfaces  of  the  tibia  and  femur  was 
destroyed  by  ulceration,  the  ulceration 
having  taken  place  principally,  but  not 
entirely,  near  the  circumference.  The 
cartilage  of  the  patella  and  the  semilunar 
cartilages  were  entire,  but  the  latter  in 
some  parts  were  softer  than  usual.  The 
bones  were  free  from  disease.  There 
was  no  pus  or  other  fluid  in  the  joint. 

The  dissection  of  this  case,  in  which 
the  ulceration  of  the  cartila«:inous  sur- 
faces  was  evidently  the  primary  disease, 
explains  well  the  nature  of,  at  least,  many 
cases  of  that  species  of  white  swelling, 
which  some  authors  have  described,  in 
which  there  is  long  continued  and  severe 
pain  in  the  joint,  before  any  tumour  is 
observable. 

CASE  XXVIIT. 


William  Bowels,  eighteen  years  of  age 
was  admitted  into  St.  George^s  Hospital 


(      126      ) 

on  the  1st  of  December  1810.  He  said 
that  about  eleven  months  previous  to  his 
admission,  he  had  been  seized  with  pain 
in  his  right  knee,  which  was  so  severe  as  to 
keep  him  frequently  awake  at  night.  Six 
weeks  after  the  pain  attacked  him,  the 
joint,  for  the  first  time,  became  swollen. 
He  now  applied  to  a  practitioner,  under 
whose  treatment,  joined  with  perfect  rest, 
the  pain  and  swelling  subsided,  so  that 
he  was  able  to  walk  about.  In  the  Sep- 
tember following,  having  returned  to  his 
usual  occupations,  and  used  the  joint  a 
good  deal,  the  pain  and  swelling  re- 
turned. 

At  the  time  of  his  admission,  the  af- 
fected knee  was  about  an  inch  and  a  half 
in  circumference  larger  than  the  other. 
The  swelling  had  the  form  of  the  articu- 
lating ends  of  the  bones.  The  leg  was 
half  bent,  and  all  attempts  to  give  it  mo- 
tion gave  great  uneasiness.  The  pain, 
which  he  experienced,  was  great  at  all 
times,  but  particularly  at  night,  when  it 
very  much  disturbed  his  rest. 


(      127     ) 

Soon  after  his  admission,  an  abscess 
was  discovered  on  the  outside  of  the 
knee,  which  burst  in  the  beginning  of 
February,  and  discharged  a  large  quanti- 
ty of  matter.  On  the  18th  of  March, 
the  limb  was  removed  by  amputation. 

On  examining  the  joint,  the  greater 
part  of  the  cartilaginous  surfaces  of  the 
tibia,  femur,  and  patella,  were  found  de- 
stroyed by  ulceration.  IVliere  the  carti- 
lage was  destroyed  the  exposed  bone  was 
carious,  and  in  some  places  covered  by  a 
thin  layer  of  coagulable  lymph;  but  in 
other  respects,  the  bone  was  free  from 
disease.  There  were  scarcely  any  remains 
of  the  semilunar  cartilages.  The  joint 
contained  pus,  and  the  abscess  in  the 
joint  had  made  its  way  into  the  external 
parts,  through  an  ulcerated  opening  in 
the  synovial  membrane.  The  synovial 
membrane  was  in  a  natural  state,  except 
that,  in  a  few  places,  there  was  a  thin 
layer  of  coagulable  lymph  on  its  surface, 
which  evidently  had  been  recently  effused. 


(      128      ) 

The  external  lateral  ligament  was  de- 
stroyed by  the  abscess:  the  other  liga- 
ments were  entire. 

In  this  case,  the  principal  disease  ob- 
served in  the  dissection,  was  the  ulcerated 
state  of  the  cartilages.  There  was  no 
affection  of  the  synovial  membrane  be- 
yond what  might  be  considered  as  arising 
from  the  formation  of  pus  in  the  joint, 
and  the  bursting  of  the  abscess  externally. 
Where  inflammation  of  this  membrane 
is  the  primary  disease,  swelling  takes 
place  often  in  a  few  hours,  always  within 
two  or  three  days,  from  the  beginning 
of  the  attack;  whereas  in  this  instance, 
the  constant  answer,  which  the  patient 
gave  to  the  repeated  enquiries  made  of 
liim,  was,  that  he  had  had  violent  pain 
for  six  weeks  before  the  joint  was  ob- 
served to  be  enlarged.  From  all  these  cir- 
cumstances, Ave  may  conclude,  that  in 
this  case  as  well  as  in  the  last,  the  carti- 
lasces  were  the  ori<ji:inal  seat  of  the  disease, 
and  that  the  morbid  appearances  observed 
in  the  soft  parts,  were  the  consequence 


(     129     ) 

of  the  formatioQ  of  the  abscess  in   the 
joint. 


The  same  conclusion  may  be  drawn 
respecting  the  two  cases  which  follow. 

CASE  XXIX. 

Mary  Anderson,  twenty-eight  years  of 
age,  was  admitted  into  St.  George's  Hos- 
pital, on  the  6th  of  April,  1815. 

At  this  time,  she  complained  of  intense 
pain  in  the  right  knee,  which  was  parti- 
cularly severe  at  night,  so  as  exceedingly 
to  interrupt  her  rest.  The  pain  was 
referred  principally  to  the  head  of  the 
tibia.  There  was  a  slight  swelling  of  the 
joint,  having  the  form  of  the  articulating 
ends  of  the  bones,  and  not  giving  to  the 
hand  the  smallest  sense  of  fluctuation. 
The  leg  admitted  of  being  moved  on  the 
thigh,  but  all  motion  aggravated  the  pain. 

ISTo    more    particular    account   of  the 
18 


(  I'^o  ) 

previous  history  of  the  case  could  be  pro- 
cured than  the  following;  that  she  had 
laboured  under  pains  of  the  right  knee 
for  nearly  six  years,  which  had  been  oc- 
casionally relieved;  and  that  in  the  first 
instance  the  pain  had  been  unattended 
by  swelling. 

Immediately  on  her  admission,  an  issue 
was  made  with  caustic  on  each  side  of 
the  patella.  On  the  9th  of  April  the  pain 
had  vei'y  much  abated.  The  issues  were 
kept  open  by  the  occasional  application 
of  caustic;  and  the  pains  very  soon  left 
her,  and  the  swelling  tliminished. 

About  the  8th  of  June,  she  began  to 
experience  a  return  of  the  pains  in  the 
knee,  and,  in  the  course  of  four  or  five 
days,  they  were  so  severe  as  to  keep  her 
awuke  at  night.  There  were  convulsive 
startings  of  the  limb,  and,  the  joint  was 
swollen  in  a  greater  degree  than  for- 
merly. The  pains  increased  in  violence, 
and  her  health  began  to  suffer  consider- 
ably. On  the  3d  of  July,  the  limb  was 
amputated. 


(     131     ) 

On  cxamininji;  tlic  knee,  some  lymph 
and  serum  were  found  effused  into  the 
cclhilar  membrane  external  to  it. 

The  cavity  of  the  joint  contained  about 
half  an  ounce  of  thin  purulent  fluid. 
The  cartilage  covering  the  j)atella  was, 
in  some  parts,  in  a  natural  state;  in  others 
it  had  tlie  fibrous  structure,  wliich  I  have 
described  in  a  former  part  of  this  chapter; 
and  in  others,  it  Avas  completely  destroyed 
by  ulceration,  so  as  to  expose  the  surface 
of  the  bone.  The  cartilage  covering  the 
articulating  extremity  of  the  femur,  pre- 
sented the  same  variety  of  appearances. 
On  the  iuside  there  was  a  spot  of  some 
extent,  which,  instead  of  cartilage,  was 
covered  by  an  organized  substance,  re- 
sembling the  substance  of  adhesions,  but 
somewhat  more  dense  in  its  structure;  ,as 
if  the  cartilage  had  been  formerly  des- 
troyed at  this  part,  and  coagulable  lyniph 
had  been  effused  on  the  ulcerated  surface 
of  bone,  which  had  afterwards  become 
organized. 


■   (      132      ) 

The  cartilages  of  the  tibia  were  ulcer- 
ated for  a  small  extent. 

The  synovial  membrane  in  general 
"\Tas  in  a  natural  state.  In  some  places 
it  was  slightly  inflamed.  On  the  outside 
of  the  joint,  it  was  inflamed  in  a  greater 
degree  than  elsewhere,  and  thickened,  and 
had  begun  to  ulcerate,  evidently  in  con- 
sequence of  the  abscess  in  the  joint,  having 
begun  to  make  its  way  to  the  external 
surface. 

The  bones  possessed  their  natural  tex- 
ture and  hardness. 

CASE  XXX. 

Jane  Bannister,  forty  years  of  age.  was 
admitted  into  St  George's  Hospital,  in 
September,  1810,  on  account  of  a  disease 
in  her  risrht  foot.     She  save  the  following: 

o  o  o 

account  of  her  case. 

In  the  September  of  the  preceding 
year  she  wrenched  her  instep,  and  soon 
afterwards    experienced   violent   pain    in 


(      133      ) 

iliis  part,  so  that  she  was  unable  to  stand 
on  that  foot,  and  her  rest  was  much  dis- 
turbed at  night.  The  pain  continued  very 
severe,  and  at  the  end  ot*  four  months, 
she  observed  for  the  first  time,  a  slight 
swelling  on  the  inside  of  the  foot.  This 
v/as  occasioned  by  an  abscess,  which  was 
opened  by  her  medical  attendant  in  the 
April  following. 

At  the  time  of  her  admission  into  the 
hospital,  the  whole  foot  was  swollen,  and 
«.he  complained  of  violent  pain  in  it.  The 
abscess  continued  open,  discharging  a 
small  quantity  of  pus.  On  introducing 
a  probe  into  the  orifice,  an  exposed  sur- 
face of  bone  was  felt.  Several  appli- 
cations were  made  without  benefit,  and 
the  leg  was  amputated  on  the  25th  of 
February,  18H. 

On  examining  the  amputated  foot,  the 
cartilages  of  the  joint  formed  by  the  as- 
traffalus  and  os  naviculare  were  found 
destroyed  by  ulceration,  and  a  portion  of 
I  he  astragalus  was  dead,  and  underfi;oing 


(  I'^i  > 

the  process  of  exfoliation..  The  cartikigos 
of  the  joints  formed  hj  the  cuneiform 
bones  uith  each  other,  with  the  os  navi- 
culare,  and  witli  the  metatarsal  bones, 
were  in  like  manner  destroyed,  and  the 
exposed  surfaces  of  bone  were  carious.  The 
abscess  communicated  with  the  carious 
joints.  The  ligaments  and  synovial  mem- 
brane were  in  a  natural  state,  except  in 
a  few  spots,  where  they  were  destroyed 
by  the  abscess.  The  bones  possessed 
their  natural  texture  and  liardness.  The 
cellular  membrane  of  the  foot  contained 
coagiilable  lymph  and  serum. 


It  would  be  needless  to  add  to  the 
foregoing  an  account  of  T)tlier  cases,  in 
which  the  disease  was  in  a  still  more  ad- 
yanced  stage.  Tlie  progress  of  it,  in 
other  joints,  corresponds  witli  that  in  the 
hip,  and  whatever  may  be  the  joint  af- 
fected, there  is  ultimately  the  same  com- 
plete destruction   of  the  cartilages,  and 


(      l'^5      ) 

[\e  ravages 
among' the  bones  and  soft  parts. 


he  same  extensive  ravages  are  committed 


In  some  cases  the  nlceration  of  the 
cartilage  of  a  joint  begins  on  that  surface, 
^vhich  is  connected  to  the  bone,  and  from 
having  observed  this  circumstance,  I  was 
k^d,  at  first,  to  adopt  an  opinion,  which  1 
heard  stated  to  liave  been  that  of  Mr, 
Hunter,  and  which  appeared  to  be  war- 
ranted by  tlie  small  degree  of  vascularity 
which  cartilage  possesses,  that  ulceration 
of  ittak€s  place,  not  from  the  action  of 
-its  own  vessels,  but  in  consequence  of  it 
*^being  acted  on  by  the  vessels  of  the  bone, 
'to  which  it  is  connected.  I  afterwards 
found,  that  in  many  instances,  previously 
to  ulceration,  the  cartilaci'e  uudero-oes  a 
remarkable  change  of  texture,  becoming 
soft,  and  assuming  a  fibrous  appearance, 
thence  I  was  led  to  conclude  that  this 
opinion  is  not  altogether  correct,  and  I 
am  now  able  to  adduce  the  two  following 


(      136      ) 

cases,  which  seem  to  prove  that  cartilage^ 
as  well  as  other  parts,  is  capable  of  ulcer- 
ating from  the  action  of  its  own  vessels. 

CASE  XXXI. 

A  boy,  twelve  years  of  agCj  on  the 
28th  of  June,  1809,  fell  from  a  height, 
and  pitched  on  one  of  his  knees.  When 
he  was  brought  to  the  hospital,  he  was 
found  to  have  a  compound  fracture  of  the 
femur.  For  some  days  he  appeared  to  go 
on  well,  but  afterwards  an  abscess  formed 
in  the  thigh,  extending  as  high  as  the 
nates;  and  he  sunk  and  died  on  the  2 1st 
of  July.  On  examining  the  knee-joint 
after  death,  the  cartilage  covering  the 
condyles  of  the  femur,  and  that  covering 
the  head  of  the  tibia  were  found,  in  some 
parts,  entirely  absorbed,  so  that  the  bone 
was  exposed;  and  in  other  parts  it  was 
absorbed  on  the  surface  towards  the  cavity 
of  the  joint,  while  the  layer  of  it  next  to 
the  bone   retained  its    natural  adhesion. 


(     137     ) 

and  its  natural  structure.  The  cartilage, 
in  these  parts,  was  formed  into  grooves, 
having  an  appearance,  as  if  the  greater 
portion  of  its  substance  had  been  removed 
with  a  chisel. 

CASE  XXXII. 

A  middle-aged  man  met  with  an  injury 
of  the  knee,  which  was  followed  by  in- 
flammation and  suppuration,  and  he  died 
in  St.  George's  Hospital,  on  the  30th 
of  August,  1809. 

On  examining  the  joint  after  death, 
the  cartilage  covering  the  condyles  of  the 
femur,  and  the  head  of  the  tibia,  was 
found  entirely  destroyed  towards  the  cir- 
cumference, so  that  the  bone  was  exposed. 
Elsewhere,  only  a  thin  layer  of  cartilage 
remained;  but  this  had  its  ordinary  tex- 
ture, and  adhered  as  firmly  as  ugiial  to 
the  bone. 


(      138      ) 

As  ill  those  cases  the  cartilage  was  ah- 
sorbed  on  the  surface  towards  the  cavity 
of  the  joint,  while  t]ie  remainder  still 
adhered  to  the  bone,  it  is  evident  that  the 
absorption  must  have  taken  place  from 
the  vessels  of  the  cartilage  itself. 

In  young  persons,  before  the  period  of 
growth  is  over,  the  articular  cartilages 
possess  more  vascularity  than  in  others, 
so  that  their  vessels  are  distinctly  to  be 
seen,  and  admit  of  being  injected,  which 
is  not  the  case  in  adults;  and  this  ex- 
plains why  the  ulceration  of  the  cartilage 
takes  place  more  frequently,  and  makes 
more  rapid  progress  in  the  formerthan  in 
the  latter. 


Sect.  II. 

On  the  Symptoms  of  this  Bisease. 

The  ulceration  of  the  articular  carti- 
lages  occurs  at  any  period  of  life,  but 
principally  in  children,  or  in  adults  under 
the  middle   age.     Of  the  whole  number 


(      139      ) 

of  those,  who  have  come  under  my 
own  ohservation,  lahoiirinj^  under  this 
disease,  not  more  than  about  one  fifth 
were  above  thirty  years  of  age;  the 
youngest  was  an  infant  of  a  year  ohl; 
the  ohlest  was  a  woman  of  sixty.  As  the 
knee  is  more  liabU^  to  inflammation  of 
the  synovial  membrane,  so  is  the  hip 
more  lia])le  tlian  other  joints  to  ulceration 
of  the  cartilaginous  surfaces.  In  general 
the  disease  is  confined  to  a  single  joint; 
but  occasionally  two  or  three  joints  are 
affected  in  the  same  individual,  either  at 
the  same  time  or  in  succession.  Some- 
times the  patient  traces  the  beginning  of 
his  symptoms  to  a  local  injury;  but  for 
the  most  part  no  cause  can  be  assigned 
for  the  complaint,  and  often  the  cause,  to 
which  it  is  attributed,  appears  to  be  ima- 
ginary rather  than  real. 

Where  the  hip  is  aflccted,  the  only 
symptoms  met  with  for  some  time  are 
pain,  and  a  slight  degree  of  lameness  in  the 
lower  limb.     The  pain  at  first  is  trifling 


(      140     ) 

and  only  occasional;  afterwards  becoming 
severe  and  constant.  It  resembles  a 
good  deal  the  pain  of  rheumatism,  since 
it  often  has  no  certain  seat;  but  is  refer- 
red to  different  parts  of  the  limb  in  differ- 
ent individuals,  and  even  in  the  same  indi- 
vidual at  different  periods.  As  the  dis- 
ease advances,  the  pain  becomes  exceed- 
ingly severe,  particularly  at  night,  when 
the  patient  is  continually  roused  from  his 
sleep  by  painful  startings  of  the  limb. 
Sometimes  he  experiences  some  degree 
of  relief  from  the  pain  in  a  particular  po- 
sition of  the  joint,  and  in  no  other.  A 
patient  in  St.  George's  Hospital  never 
obtained  any  rest,  except  when  he  had 
placed  himself  on  the  edge  of  the  bed- 
stead, with  his  feet  on  the  ground,  and 
resting  his  body  on  a  pillow,  in  a  position 
between  that  of  Ijing  and  sitting. 

As  the  pain  increases  in  intensity,  it  is 
more  confined  in  its  situation.  In  tlie 
greater  number  of  instances  it  is  referred 
to  the  hip  and  the  knee  also,  and  the  pain 


(      141      ) 

in  the  knee  is  generally  the  most  sever** 
of  the  two.  At  other  times  there  is  puin 
in  the  knee,  and  none  in  the  hip.  A 
boy  in  St.  George's  Hospital  complained 
of  pain  in  the  inside  of  the  thigh,  near 
the  middle;  and  another  patient,  a  little 
girl,  referred  the  pain  to  the  sole  of  the 
foot.  Wherever  the  pain  is  situated  it  is 
aggravated  by  the  motion  of  the  joint;  but 
it  is  aggravated  in  a  still  greater  degree  b) 
whatever  occasions  pressure  of  the  ulcer- 
ated cartilaginous  surfaces  against  each 
other.  Hence  the  patient  is  unable  to  sup- 
port the  weight  of  the  body  on  the  affected 
Mmb;  and  if  he  be  placed  on  an  even  sur- 
face, in  a  horizontal  position;  and  the  hand 
of  the  surgeon  be  applied  to  the  heel  sc» 
as  to  press  the  head  of  the  femur  against 
the  concavity  of  the  acetabulum,  violent 
pain  is  the  consequence;  although  this 
be  done  in  so  careful  a  manner  that  no  I; 
the  smallest  degree  of  motion  is  given  to 
the  hip-joint.  This  circumstance  is  weH 
deserving  of  attention;  and  no  one  .^bould 


(      142     ) 

attempt  to  give  an  opinion  as  to  the  na- 
ture of  a  disease  connected  with  the  hip, 
without  haviiig  made  an  examination 
in  the  manner,  which  has  been  just 
described. 

Soon  after  the  commencement  of  the 
complaint,  the  hip  joint  is  found  to  be 
tender,  whenever  pressure  is  made  on  it 
either  before  or  behind.  The  absorbent 
g'lands  become  enlarged,  and  occasionally 
there  is  a  slight  deii;ree  of  i»'eneral  tume- 
faction  in  the  ^roiii.  In  this  there  is  no- 
thing  remarkable,  since  we  must  suppose 
that,  a,  disease  going  on  within  the  articu- 
lation must  ultimately  occasion  some  de- 
gree of  inflammation  in  the  neighbouring 
parts.  But  it  is  a  curious  circumstance, 
that  in  some  cases,  there  is  tenderness  of 
those  parts,  to  which,  though  not  diseased 
themselves,  the  pain  is  referred  from 
sympath}^  with  the  disease  in  the  hip.  I 
have  observed  this  in  tiic  knee  several 
times,  and  a  gentleman,  in  whom  the 
pain  was  referred  to  the   outside  of  tht^ 


^      148     ) 

lieg,  complained  of  great  tenderness  every 
where  in  the  course  of  the  peronseal 
nerve.  I  have  also  seen  a  slight  degree 
of  puffy  swelling  of  the  knee,  where  pain 
was  referred  to  it,  in  consequence  of 
disease  in  the  hip.  These  facts  corres- 
pond, to  what  may  he  ohserved  in  some 
other  cases,  where  pain  is  referred  to  a 
sound  part,  in  consequence  of  a  sym- 
pathy existing  hetween  it,  and  some 
other  part  that  lahours  under  disease; 
for  example,  I  have  known  the  passage 
of  a  calculus  down  the  ureter,  to  occasion 
not  only  pain,  hut  tenderness,  swelling,  and 
no  trifling  inflammation  of  the  testicle. 

When  the  disease  has  existed  for  some 
time,  the  nates  undergo  a  remarkable 
alteration  in  their  form.  They  become 
wasted  and  less  prominent:  so  that  in- 
stead of  their  usual  convexity,  they 
present  the  appearance  of  a  flattened 
surface:  they  are  flaccid  to  the  touch, 
and  hang  more  loosely  towards  the  lower 
edge;  and  they  have  the  appearance  of 
being  wider  than  those  of  the  other  side. 


(      *44     ) 

In  a  very  few  cases,  in  the  abvanced 
stage  of  the  disease,  the  nates  are  really 
wider,  in  consequence  of  the  acetabulum 
being  filled  with  coagulable  lymph  and 
matter,  and  the  head  of  the  femur  being 
pushed  out  of  its  natural  situation.  But 
in  general  the  increased  breadth  of  the 
nates  is  only  apparent,  and  on  an  accu- 
rate measurement  no  difference  will  be 
found  between  the  nates  of  one  side,  and 
those  of  the  other.  The  alteration  in 
the  figure  of  the  parts  in  those  cases, 
may  arise  partly  from  the  position,  in 
which  the  patient  usually  places  himself, 
when  he  stands  erect;  but  the  principal 
cause,  to  which  it  is  to  be  attributed,  is 
the  wasting  of  the  large  fleshy  bellies  of 
the  glutsei  muscles  from  want  of  use; 
and  this  has  been  ascertained,  by  re- 
peated, and  accurate  examinations  of  the 
living,  and  numerous  dissections  of  the 
dead  body.* 

*  This  alteration  in  the  form   of  the   nates  is    a- 
53'mptom,  but  is  not  in  itself  10  le  considered  as   at 


(     145     ) 

Another  symptom,  which  occurs  in  this 
disease,  is  an  alteration  in  the  length  of 
the  limb.  1st,  In  the  early  stage  of  the 
disease  the  patient  often  complains,  that 
the  limb  on  the  affected  side  is  longer 
than  the  other.  This  cannot  be  explained 
on  the  supposition  of  the  acetabulum 
being  filled  with  pus,  or  solid  substance, 
since  it  would  cause  the  head  of  the  fe^ 
mur  to  be  pushed  outwards  rather  than 
downwards.  The  fact  is  that  there  is 
only  an  apparent,  and  no  real  elongation 
of  the  limb.  If  the  patient  be  placed  on 
his  back  in  the  horizontal  position,   so 

certain  diagnostic  mark  of  disease  in  the  hip-joint; 
as  it  may  be  observed  in  other  cases,  where  from 
any  cause,  the  glutai  muscles  have  been  for  a  con- 
siderable time  in  a  state  of  inaction.  Thus  children 
arc  subject  to  a  paralytic  state  of  the  muscles  of  the 
lower  limb,  and  in  this  complaint,  if  the  muscles  are 
affected  as  high  as  the  pelvis,  the  nates  present  to  the 
eye  the  same  appearance.  It  may  be  noticed  also 
where  there  is  disease  of  the  thigh-bone,  or  where 
from  any  other  cause,  the  motion  of  the  hip  is  painful 
and  difRcult. 

20 


i(      146     ) 

that  both  thighs  make  the  same  angle 
with  the  pelvis,  the  fbot  on  the  diseased 
side  may  at  first  appear  as  much  as  two 
or  three  inches  lower  than  the  oppo- 
site foot:  but,  if  the  distance  be  accur- 
ately measured  with  a  tape,  from  the 
anterior  superior  spinous  pi*ocess  of  the 
ilium  to  the  patella,  no  difference  is  per- 
ceptible. The  apparent  elongation  is  pro- 
duced by  the  position  of  the  pelvis  being 
altered,  in  such  a  way  that  the  crista  of 
one  ilium  is  visibly  depressed  below  the 
level  of  that  of  the  other.  It  is  easy  to 
understand  how  this  effect  is  produced, 
by  observing  the  position,  in  which  the 
patient  places  himself,  when  he  stands 
erect.  He  supports  the  weight  of  hi§ 
body  on  the  sound  limb,  the  hip  and 
knee  of  which  are  in  consequence  main- 
tained in  the  state  of  extension.  At  the 
same  time  the  opposite  limb  is  inclined 
forward,  and  the  foot  on  the  side  of  the 
disease  is  placed  on  the  ground,  consider- 
ably anterier  to  the  other,  not  for  the 
purpose  of  supporting  the  superincum- 


(     147     ) 

bent  weight,  but  for  that  of  keeping  the 
person  steady,  and  preserving  the  equi- 
librium. Of  course  this  cannot  be  done 
without  the  pelvis  on  the  same  side  being 
depressed.  The  inclination  of  the  pelvis 
is  necessarily  attended  with  a  lateral  cur- 
vature of  the  spine,  and  hence  it  happens 
that  one  shoulder  is  higher  than  the  other, 
and  that  the  whole  figure  is  in  some  de- 
gree distorted.  All  these  symptoms  will 
disappear  in  the  course  of  a  few  weeks,  if 
the  patient  under  these  circumstances  be 
confined  to  his  bed  and  the  horizontal 
position^  except  in  some  instances,  where, 
in  consequence  of  their  having  occurred 
in  ayoungand  growing  person,  and  having 
already  been  allowed  to  exist  for  a  con- 
siderable time,  the  shape  of  the  parts  has 
become  adapted  to  their  new  situation, 
and  the  alteration  of  the  figure  may  con- 
tinue durins:  life. 

2.  In  a  few  cases,  where  the  patient  is 
in  the  erect  position,  it  may  be  observed 
that  the  foot,  which  belongs  to  the  affected 


(     148     ) 

limb  is  not  inclined  more  forward  than 
the  other,  hut  that  the  toes  only  are  in 
contact  with  the  ground,  and  the  heel 
raised;  at  the  same  time  that  the  hip  and 
knee  are  a  little  bent.  This  answers  to 
the  patient  the  same  purpose  of  enabling 
liim  to  throw  the  weight  of  his  body  on 
the  other  footj  but  it  produces  an  in- 
clination of  the  pelvis  in  the  opposite 
direction.  The  crista  of  the  ilium  is 
higher  than  natural,  and  there  is  an  ap- 
parent shortening,  instead  of  elongation, 
of  the  limb  on  the  side  of  the  disease. 

3.  In  the  very  advanced  stage  of  the 
disease,  when  the  head  of  the  femur  has 
been  completely  destroyed  by  ulceration, 
there  is  nothing  to  prevent  the  muscles 
from  pulling  the  bone  upwards.  Tliis 
may  be  compared  to  a  case  of  fractured 
neck  of  the  femur.  The  limb  is  not  only 
apparently,  but  it  is  really  shortened:  the 
foot  may  he  rotated  inwards,  but,  if  left  to 
itself,  it  generally  is  turned  outwards. 

4.  In  other  cases,  the  limb  is  shortened; 
the  thigh  is  bent  forwards;  the  toes  are 


(     149     ) 

turned  iiiAvards,  and  do  not  admit  of 
being  turned  outwards;  and  there  is  every 
symptom  of  a  dislocation  of  the  hip  up- 
wards  and  outwards.  The  following  case 
fully  explains  the  cause  of  those  ap- 
pearances. 

CASE  XXXIII. 

— —  Taylor,  a  middle-aged  man^  was 
idmitted  into  St  George's  Hospital,  in 
the  autumn  of  1805,  on  account  of  a  dis- 
ease in  his  left  hip.  He  laboured  also 
under  other  complaints,  and  he  died  in 
the  February  following. 

On  inspecting  the  body,  the  soft  parts 
in  the  neighbourhood  of  the  joint  were 
found  slightly  inflamed,  and  coagulable 
lymph  had  been  effused  into  the  cellular 
membrane  round  the  capsular  ligament. 

There  were  no  remains  of  the  round 
ligament. 

The  cartilages  had  been  destroyed  by 
ulceration,  except  in  a  few  spots. 


(      150      ) 

The  bones  on  their  exposed  s^urfacef? 
Nyere  carious;  but  they  retained  their  na- 
tural form  and  size.  The  acetabulum 
was  almost  completely  filled  with  puis  and 
coagulable  lymph;  the  latter  adhering  to 
the  carious  bone,  and  having  become 
highly  vascular.  The  head  of  the  femur 
was  lodged  on  the  dorsum  of  the  ilium. 
The  capsular  ligament  and  synovial  mem- 
brane were  much  dilated;  and,  at  tlie 
superior  part,  their  attachment  to  the 
bone  was  thrust  upwards,  so  that  al- 
though the  head  of  the  femur  was  no 
longer  in  the  acetabulum,  it  was  still 
within  the  cavity  of  the  joint. 

Since  the  man  did  not  attribute  this 
disease  to  any  local  injury,  we  may  con- 
clude that  the  ulceration  of  the  carti- 
lage was  the  primary  aifection,  and  that 
the  dislocation  had  been  produced  in 
consequence  of  the  head  of  the  femur 
having  been  first  pushed  outwards  by  the 
coagulable  lymph  and  pus,  which  occu- 
pied the  cavity  of  the  joint,   and   then 


(      1-51      ) 

ttrawii  upwards  by  the  action  of  the 
muscles  inserted  into  the  great  tro- 
chanter.* 

The  shortening  of  the  limb,  which 
takes  place  in  the  advanced  stage  of  the 
disease  is  usually,  but  not  always,  the 
precursor  of  abscess.  The  formation  of 
matter  is  also  indicated  by  an  aggravation 
of  the  pain,  by  more  frequent  spasms  of 
the  muscles,  by  a  greater  wasting  of  the 
whole  limb,  and  by  the  circumstance  of 
the  thigh  becoming  bent  forward,  and 
being  incapable  of  extension,  without  such 
an  increase  of  the  patient's  sufferings  as 
he  will  be  unable  to  endure.  At  the 
same  time  the  pulse  becomes  quick,  the 
tongue  furred,  and  the  whole  system  is 
in  a  state  of  preternatural  excitement. 
The   abscess  usually  shews  itself  in  the 

*  This  case  affords  an  example  of  the  dislocation 
of  the  hip  from  an  internal  cause,  which  some  surgical 
writers  have  described,  and  it  is  probable  that  in  the 
majority  of  such  cases,  the  dislocation  is  produced  in 
?:hc  same  manner. 


-     (      152     ) 

form  of  a  large  tumor  over  the  vastus  ex- 
ternus  muscle;  sometimes  on  the  inside 
of  the  thigh  near  the  middle;  and  occa- 
sionally two  or  three  ahscesses  appear  in 
different  parts,  and  burst  in  succession. 
The  abscesses  discharge  a  large  quantity 
of  thin  pus,  and  in  the  worst  cases  a 
copious  suppuration  continues,  until  the 
powers  of  the  patient  are  exhausted,  and 
enfeebled  and  emaciated  he  sinks  under 
the  symptoms  of  a  hectic  fever.  That  an 
adult  should  recover  under  these  circum- 
stances is  so  rare  an  occurrence,  that  the 
surgeon  can  never  be  justified  in  giving 
any  but  the  most  unfavourable  prognosis. 
Children  recover  more  frequently  in  tliis 
advanced  stage  of  the  disease,  but  not 
without  a  complete  anchylosis  of  the 
joint.  If  suppuration  has  not  taken  place, 
I  believe  it  rarely  happens  that  the  limb 
after  the  cure  does  not  regain  its  natui*al 
degree  of  mobility.* 


*  However  difficult  the  diagnosis  of  this  disease 
of  the  hip  may  be  in  its  early  stage,  it  may  be  made 


(      153     ) 

AYhen  the  cartilages   of  tlic  knee  arf^ 
ulcerated,   there    is  pain  in   the  afleclecl 

with  sufficient  certainty,  when  the  disease  is  somewhat 
advanced.  It  is  to  be  founded  however,  not  on  a 
single  synnptom,  but  on  the  combination  of  symp- 
toms, and  on  the  history  of  their  progress,  so  tliat  no 
degree  of  experience  can  enable  the  surgeon  to  form 
his  judgment  correctly,  without  a  careful  investiga- 
tion of  the  circnmstances  of  the  case  before  him. 

The  morhid  affections  most  liable  to  be  confound- 
ed with  the  ulceration  of  the  cartilage  of  the  hip  are 
the  following. 

1.  Inflammation  of  the  synovial  membrane  of  the 
hip,  of  which  I  have  spoken  in  a  former  chapter. 

2.  Chronic  inflammation  of  the  soft  parts  in  the 
neighbourhood  of  the  hip,  terminating  in  the  form- 
ation of  a  chronic  abscess.  Here  there  is  pain,  but 
more  confined  in  its  situation,  than  where  the  carti- 
lages of  the  hip  are  ulcerated:  the  pain  is  less  severe> 
less  aggravated  by  the  motion  of  the  joint;  not  re- 
lieved in  the  same  degree  by  rest;  not  attended  by  a 
flattening,  and  very  soon  followed  by  a  tumtfactiou 
of  the  nates. 

3.  l"he  disease  which  has  itr,  origin  in  the  cancel- 
lous structure  of  the  bone?:,  of  which  I  shall  speak 
hereafter. 

4.  I  have  seen  several  cases  in  which  I  suspected 
the  symptoms  to  depend  on  a  morbid  condition  of  the 

21 


(      154     ) 

joint;  at  first  it  is  slig'ht  and  only  occa- 
sional, and  in  the  early  stage  of  the 
disease,  it  is  completely  relieved  by  re- 
maining in  a  state  of  rest  for  a  few  days, 
but  it  returns  as  soon  as  the  patient  re- 
sumes the  exercise  of  the  limb.  By 
degrees  the  pain  becomes  constant  and 
very  severe,  particularly  at  night,  when  it 
disturbs  the  patient  by  continually  rousing 
him  from  his  sleep.  The  pain  is  referred 
principally  to  the  inside  of  the  head  of 
the  tibia,  but  sometimes  a  slighter  degree 
of  pain  extends  down  the  whole  of  that 
bone.  The  pain  is  aggravated  by  motion^ 
so  that  the  patient  keeps  the  limb  con- 
sciatic  nerve;  and  in  which  they  bore  a  certain  ana- 
logy to  the  disease  in  question.  There  was  pain  re- 
ferred to  the  parts,  to  which  the  sciatic  nerve  is  dis- 
tributed; but  not  very  severe,  nor  materially  aggra- 
vated in  consequence  of  the  disease  being  neglectedo 
There  was  tenderness  in  the  situation  of  the  nerve 
on  the  posterior  part  of  the  hip  and  thigh,  the  ten.- 
derness  being  usually  more  considerable  at  one  par- 
ticular point.  The  symptoms  were  relieved  princi- 
pally by  the  application  of  blisters  over  the  trunk  of 
the  nerve,  which  was  suspected  to  be  the  seat  of  the 
malady. 


(      155     ) 

^tautly  in  one  position,  and  generally  half 
bent:  and  lie  neyer  attempts  to  support 
the  weight  of  the  body  on  the  foot  of  this 
side. 

The  ulceration  of  the  cartilages  of  the 
knee  differs  with  respect  to  its  symptoms, 
from  inflammation  of  the  synovial  mem- 
brane, in  this;  that  the  pain  in  the  former 
is  slight  in  the  beginning,  and  gradually 
becomes  very  intense,  which  is  the  very 
reverse  of  what  happens  in  the  latter. 
But  there  is  another  circumstance,  which 
forms  a  remarkable  distinction  between 
the  ulceration  of  the  cartilages,  and  most 
other  diseases,  towhich  this  joint  is  liable. 
The  pain  in  tlie  first  instance  is  unat- 
tended by  any  evident  swelling;  which 
comes  on,  never  in  less  than  four  or  five 
weeks,  and  often  not  until  several  months 
have  elapsed  from  tlie  commencement  of 
the  disease.  The  reason  of  this  is  too 
unanifest  to  require  explanation,- and  it  is 
equall^Mmnecessary  to  point  out  the  iiii- 
portance  of  it,  as  affordnig  tlie  means  of 


(      15t>      ) 

making  a  more  ready  diagnosis.  Wc 
must  not  indeed  conclude  indiscrimi- 
nately, whenever  tliere  is  a  slight  pain  in 
the  knee,  unattended  hy  swelling,  that 
the  cartilages  are  in  a  state  of  ulceration, 
since  this  symptom  may  equally  arise 
from  inflammation  of  the  hones  them- 
selves; of  the  ligaments;  of  the  fatty 
substance  of  the  joint,  or  from  simple 
nervous  affection;  and  instances  will 
occur  to  every  surgeon,  where  there  is 
reason  to  believe  that  the  above  men- 
tioned symptom  arises  from  one  or  other 
of  these  causes^  But  when  the  pain  con- 
tinues to  increase,  and  at  last  becomes 
very  severe;  wlien  it  is  aggravated  by 
the  motion  of  the  joint,  and  by  the  pres- 
sure of  the  articulating  surf\ices  against 
each  other:  and  when  after  a  time  a 
slight  tumefaction  takes  place,  sucli  as  I 
shall  presently  describe;  we  may  con- 
clude that  the  disease  consists  in  an  ulcer- 
ation of  the  cartilages;  and  in  all  such 
prases,  which  have  come  under  my  own 


(      <5T     ) 

observation  their  subsequent  progress, 
and  the  morbid  appearances  presented 
by  dissection,  where  an  opportunity  has 
occurred  of  observing  them,  have  fully 
justified  this  conclusion. 

The  swelling,  which  attends  this  disease 
in  the  knee,  differs  from  that,  which  oc- 
curs in  either  of  those  of  the  synovial 
membrane,  which  I  have  formerly  de- 
scribed. It  arises  from  a  slight  degree  of 
inflammation  having  taken  place  in  the 
cellular  membrane  external  to  the  joint, 
in  consequence  of  the  disease  within  it. 
The  swelling  is  usually  trifling,  appearing 
greater  than  it  really  is,  in  consequence  of 
the  wasting  of  the  muscles  of  the  limb.  It 
has  the  form  of  the  articulating  ends  of  the 
bones;  that  is  the  natural  form  of  the  joint. 
ISo  fluctuation  is  perceptible,  as  where  the 
synovial  membrane  is  inflamed:  nor  is 
there  the  peculiar  elasticity,  which  exists, 
where  the  synovial  membrane  has  under- 
gone a  morbid  alteration  of  structure. 

But  a  few  cases   occur,  in  which  this 


(      158      ) 

disease  is  attended  with  a  collection  (A' 
fluid  in  the  joint,  and  in  which  therefore 
the  tumor  has  a  form  different  from  that 
which  has  heen  described,  and  giving  to 
the  hand  a  distinct  sense  of  fluctuation. 

1st,  Inflammation  of  the  synovial  mem- 
brane may  occur  as  a  secondary  disease, 
ulceration  of  the  cartilages  having  pre- 
ceded it,  and  the  eifusion  of  synovia  into 
tlie  joint  being  the  consequence  of  it. 
This  1  supposed  to  have  happened  in  the 
case  of  John  Child,  which  will  be  related 
hereafter. 

2dly.  In  an  advanced  stage  of  ulcer- 
ation of  the  cartilages,  where  an  abscess 
is  formed,  it  occasions  ulceration  of  the 
soft  parts,  and  usually  makes  its  way  to 
the  skin;  but  sometimes  the  pus  is  col- 
lected in  the  joint;  distending  the  syno- 
vial membrane,  and  causing  a  tumor 
very  similar  to  that,  which  would  arise 
fi'om  it  being  distended  with  synovia.  In 
these  cases,  the  surgeon  must  form  his 
diagnosis,  by  attending  to  the  previous 


(      159      ) 

liistory;  by  observing  tbe  degree  and  the 
kind  of  pain  of  ^vhich  tbe  patient  com- 
plains; and  the  state  of  his  general  health; 
and  by  bearing  in  mind  this  circumstance, 
that  blisters  very  seldom  fail  in  procm*ing 
absorption  of  the  too  abundant  synovia, 
and  that  they  never  cause  the  absorption 
of  pus. 

As  the  ulceration  of  the  cartilages  is 
sometimes  followed  by  dislocation  of  the 
hip;  so  we  find  that  dislocation  of  the 
knee  occasionally  takes  place  from  the 
same  cause.  Where  there  has  been  con- 
siderable distension  of  the  soft  parts  in 
consequence  of  ulceration  extending  to 
them,  the  head  of  the  tibia  is  gradually 
•drawn  backwards  by  the  action  of  the 
flexor  muscles  and  lodged  in  tile  ham; 
and  I  have  even  known  this  to  happen 
where  abscess  has  never  formed,  the 
patient  ultimately  recovering  with  a  stiff 
joint  and  disfigured  limb.  In  such  a 
case,  the  condyles  of  the  femur  make  an 
unusual  projection,  and  the  articulating 


^      160      ) 

surfaces  of  tlie  bones  are  partially  or  en- 
tirely separated  from  each  otlier. 

The  symptoms  produced  by  the  ulcer- 
ation of  the  cartilages  of  other  joints  cor- 
respond very  nearly  with  those  already 
described.  The  principal  diagnostic  mark 
is  the  pain,  which  is  experienced  in  the 
beginning  unattended  by  swelling.  The 
|)ain  is  referred  to  the  part,  which  is  the 
victual  seat  of  the  disease:  but  where  th6 
elbow  is  affected,  the  more  violent  pain 
in  this  joint  is  accompanied  by  a  slighter 
degree  of  pain  in  the  lower  part  of  the 
fore-arm  and  wrist;  and  where  the  disease 
is  in  the  shoulder  there  is  often  a  pain- 
ful sensation,  extending  down  the  whole 
of  the  bone  of  the  arm.  In  all  cases  the 
pain  is  much  increased,  when  the  articu- 
lating surfaces  are  pressed  against  each 
other,  and  in  the  first  instance  it  is  unat- 
tended by  swelling.  In  cases  of  ulceration 
of  the  cartilages  of  the  shoulder,  the  joint 
is  smaller  than  natural,  in  consequence  of 
the  wasting  of  the  deltoid  muscle. 


(      161      ) 

Whatever  joint  is  the  seat  of  the  dis- 
ease, the  formation  of  abscess  is  always 
attended  with  an  aggravation  of  all  the 
symptoms.  But  the  degree,  in  whicli  the 
general  system  is  disturbed,  when  suppur- 
ation is  established,  depends  on  various 
circumstances;  on  the  age  and  powers  of 
the  patient;  on  the  size  of  the  affected 
joint;  and  on  its  situation.  An  abscess 
connected  with  a  deep-seated  joint  occa- 
sions more  extensive  mischief  of  the  soft 
jiarts,  before  it  reaches  the  surface,  and 
therefore  is  productive  of  more  serious 
consequences,  than  one  which  is  connected 
with  a  joint,  that  is  situated  superficially. 

The  progress  of  the  ulceration  of  the 
cartilages  varies,  w  ith  respect  to  time,  in 
different  cases,  but  it  is  generally  tedious. 
In  one  case,  where  violent  pain  had  ex- 
isted in  the  knee,  with  little  or  no  swel- 
ling, for  two  years  and  a  half  previous 
to  amputation,  I  had  an  opportunity  of 
examining  the  diseased  joint,  and  found 
the  cartilages  destroyed  for  only  a  small 
22 


(      162      ) 

extent;  a  dram  and  a  half  of  pus  in  the 
articular  cavity,  and  no  morbid  appear- 
ances of  the  soft  parts,  with  the  excep- 
tion of  a  Tcrj  slight  inflammation,  which 
had  been  induced  in  the  synovial  mem- 
brane, and  the  effusion  of  a  minute 
quantity  of  coagulable  lymph  into  the 
cellular  texture  on  its  external  surface, 
In  another  case,  the  pains  in  the  lower 
limb  had  existed  for  a  whole  year,  be- 
fore they  were  sufficient  to  attract  the 
patient's  serious  attention.  In  this  case 
no  pus  was  formed  in  the  joint;  and 
the  ultimate  recovery  was  complete,  Avith- 
out  the  smallest  detriment  to  the  motion 
of  the  limb.  Sometimes,  however,  the 
progress  of  the  disease  is  much  more  ra- 
pid. There  was  a  patient  in  St.  George's 
Hospital,  in  whom,  in  the  course  of  four 
months,  the  destruction  of  the  head  of 
the  femur  and  acetabulum  was  such,  as 
to  occasion  a  real  shortening  of  the  limb 
to  the  extent  of  an  inch. 


(      163      ) 

Sect.III. 

On  the  Treatment 

Where  the  cartilages  of  a  joint  are  ul- 
cerated, it  ma}'  well  be  supposed  that  the 
motion  of  their  surfaces  on  each  other 
must  he  favourable  to  the  progress  of  the 
ulceration.  I  have  known  some  cases,  in 
which  rest  alone  was  suilicient  to  produce 
a  cure.  In  all  cases  the  symptoms  of  the 
disease  are  aggravated  by  any  consider- 
able exercise;  and  we  may  therefore  con- 
clude that  the  keeping  the  limb  in  a  state 
of  perfect  quietude,  is  very  important,  if 
not  the  most  important,  circumstance  to 
be  attended  to  in  the  treatment. 

Issues  made  with  caustic*  have  been 

*  The  immediate  relief,  which  sometimes  follows 
the  application  of"  caustic  to  the  skin,  or  the  surface 
of  an  issue,  when  the  limb  is  under  precisely  the 
same  circumstances,  as  before,  with  respect  to  rest; 
and  the  return  of  the  symptoms,  which  in  many  in- 
stances follows   the  early  healing  of  an  issue,  sufii- 


(      164      ) 

recommended  by  many  practitioners  for 
the  cure  of  diseased  joints;  but  as  far  as 
I  know,  no  one  has  attempted  to  point 
out  the  particular  class  of  cases,  to  which 
this  remedy  is  applicable.  I  have  em- 
ployed caustic  issues,  and  seen  them 
employed,  in  a  great  number  and  variety 
of  instances,  and  have  found  them  to  be 
usually   productive    of    singular   benefit, 

ciently  prove  the  efficacy  of  this  remedy.  It  maybe 
difficult  to  explain  the  modus  operandi;  but  what 
happens  in  these  cases  seems  to  bear  no  distant  ana- 
logy to  the  suspension  of  gonorrhoea,  by  the  occur- 
rence of  inflammation  of  the  testicle,  or  the  metastasis 
of  gout  from  the  stomach  to  the  foot.  Issues  are 
employed  in  surgery  for  the  purpose  of  stopping  the 
morbid  action  of  the  animal  body:  but  it  is  probable 
that  if  made  of  too  great  an  extent,  they  would  inter- 
fere with  its  natural  actions  also.  In  a  guinea-pig, 
a  large  abscess  took  place  of  one  leg  and  thigh  in 
consequence  of  a  local  injury.  The  formation  of  the 
abscess  completely  stopped  the  growth  of  the  claws 
on  the  foot  of  this  side-.  They  wore  away  at  the 
points,  without  being  regenerated  at  the  base,  be- 
came short  and  dry,  and  readily  cracked  and  splin- 
tered; while  on  the  foot  of  the  opposite  limb  they 
continued  to  grow  as  usual,  and  possesed  their  ordi- 
nary appearance. 


(      165      ) 

where  the  cartilages  are  in  a  state  of 
ulceration,  and  to  be  of  little  or  no  ser- 
vice in  any  of  the  other  morbid  affections, 
to  which  the  joints  are  liable.  Setons 
and  blisters  kept  open  by  means  of  the 
savine  cerate  appear  to  operate  nearly  in 
the  same  manner  as  caustic  issues,  and 
may  be  used  with  advantage  in  the  same 
description  of  cases.* 

In  many  instances,  which  occur  par- 
ticularly in  hospital-practice,  the  patient, 
from  too  freely  exercising  the  limb,  brings 
on  an  inflammation  of  tlie  ulcerated  sur- 
faces  of  the  bones,  occasioning  an  aggrava- 
tion of  the  pain,  and  usually  some  degree 

*  It  may  be  expected  that  I  should  in  this  place 
offer  some  remarks  on  the  effects  of  the  application 
of  the  cautery,  which  has  been  recommended  at 
different  times,  for  the  relief  of  some  cases  of  diseased 
joints.  I  do  not  however  feel  myself  warranted  in 
giving  any  confident  opinion  as  to  the  comparative 
efficacy  of  issues  made  by  the  caustic,  and  those 
made  by  the  cautery;  my  experience  of  the  latter 
being  very  limited.  The  little,  which  I  have  had  an 
opportunity  of  observing,  has  ce^-tainly  not  led  me  to 
prefer  the  cautery  to  the  caustic. 


(      166      ) 

of  fever;  and  here  bleeding  may  be  em- 
ployed with  advantage.  Under  other  cir- 
cumstances I  have  not  known  the  loss  of 
blood  to  be  productive  of  much  benefit. 
Indeed  I  know  of  no  analogy,  that  should 
lead  us  to  expect  much  benefit  from  it, 
since  bleeding  is  not  found  to  possess  the 
power  of  stopping  tlie  progress  of  ulcers 
m  other  parts. 

In  the  early  stage,  the  warm  bath  is 
sometimes  of  service.  At  least  it  is  ca- 
pable of  relieving  the  symptoms,  if  not 
of  stopping  the  progress  of  the  disease. 

Plasters  made  of  gum  ammoniac,  and 
others  of  a  similar  nature;  embrocations 
and  Mniments  of  all  kinds,  are  entirely 
inefficacious.  Friction  is  invariably  in- 
jurious. 

I  have  shewn  in  a  former  section  that 
ulceration  of  the  articular  cartilages  may 
take  place  to  a  considerable  extent,  with- 
out suppuration  being  established.  This 
is  a  circumstance  of  much  importance, 
not  only  with  respect  to  pathological 
science,  but  also  in  a  practical  point  of 


{     167     ) 

view.  The  prospect  of  a  cure,  which 
the  employment  of  any  remedies  affords, 
is  undoubtedly  much  greater  where  ab- 
scess does  not  exist,  than  where  it  does; 
and  the  prognosis  which  the  surgeon 
gives  must  depend  in  a  great  degree  on 
the  opinion,  which  he  is  led  to  form  on 
this  subject. 

Haying  premised  these  general  observ- 
ations, I  shall  proceed  to  offer  a  few 
practical  remarks:  first,  on  tlie  treatment 
of  this  disease  in  the  hip,  and  afterwards 
in  other  joints,  without  reference  to  sup- 
puration having  taken  place;  secondly, 
on  the  plan  which  sliould  be  adopted, 
where  suppuration  is  established,  and 
there  is  a  collection  of  pus  communicat- 
ing with  the  articulai*  cavity. 

Where  the  cartilages  of  the  hip  are 
ulcerated,  the  patient  should,  in  the  first 
instance,  be  confined  to  a  couch,  if 
not  to  his  bed;  and  if  the  disease  be 
far  advanced,  the  limb  should  be  sup- 
ported by  pillows  and  cushions  properly 


(      168      ) 

diiiposed,  so  as  to  favour  the  production 
of  anchylosis,  by  allowing  it  to  vary  as 
little  as  possible  from  one  position. 

In  young  children,  blisters  are  capable 
of  affording  complete  relief.  They  may 
be  applied  to  the  nates,  round  the  great 
trochanter,  and  in  the  groin.  A  blister 
kept  open  by  means  of  the  savine  cerate 
is  usually  more  efficacious  than  a  num- 
ber of  blisters  applied  and  healed  in  suc- 
cession. 

In  children  above  the  age  of  eight  or 
ten  years,  and  in  adults  the  same  treat- 
ment is  useful  in  the  ^  cry  earW  stage  of 
the  disease;  but  in  the  more  advanced 
stage,  issues  made  with  caustic  appear  to 
be  much  more  efficacious,  and  to  be  at- 
tended on  the  whole  with  less  inconve- 
nience to  the  patient. 

The  hollow  behind  the  great  trochanter 
of  the  femur,  is  in  many  respects  the 
most  convenient  situation  for  the  applica- 
tion of  the  caustic;  but  in  some  cases 
the   application  of  it  on  the    outside   of 


(      169     ) 

the  hip  is  attended  with  better  effects. 
The  skin  of  this  part  is  in  fact  nearer  to 
the  joint,  than  the  skin  behind;  and  there 
are  some  grounds  for  the  opinion,  that 
issues  are  more  efficacious,  when  made 
near  to  the  seat  of  the  disease,  than  when 
made  at  a  distance  from  it.*  The  skin 
in  the  groin  is  still  nearer  to  the  hip  than 
on  the  outside,  but  the  large  vessels  and 
nerves  of  the  thigh  forbid  the  use  of  the 
caustic  at  this  part.     A  slough  may  be 

*  "  I  have  for  many  years  applied  caustics  above 
"  and  below  the  internal  condyle  of  the  thigh-bone, 
"  for  white  swellings  of  the  knee,  with  various  suc- 
"  cessj  and  I  have  remarked,  that  where  this  plan 
"  disappointed  my  hopes,  and  where  a  suppuration 
*'  took  place  in  the  joint,  that  the  inflammation  in  al- 
"  most  every  case  arose,  and  that  the  matter  collect- 
*'  ed  generally  made  its  way,  outwards  on  the  exter- 
"  nal  side  of  the  knee.  Observing  this  fact  i*epeat- 
"  edly,  I  was  lead  to  believe  that  the  caustic,  in  the 
"  manner  I  used  it,  checked  the  progress  of  the 
"  disease,  as  far  as  it  had  influence;  but  that  the  in- 
"  fluence  was  not  sufficient  to  pervade  the  whole  ca- 
"  vity  of  the  joint." 

Ford  on  the  Hip- Joint,  p.  194;  drst  edition, 
2^ 


(      I'O      ) 

uiade  with  the  potassa  fusa,  in  the  adult, 
half  an  inch  in  breadth  and  two  inches  in 
length  behind  the  great  trochanter.  If 
this  fails  in  giving  relief,  a  second  slough 
of  a  smaller  size  may  be  made  on  the 
anterior  edge  of  the  tensor  vaginae  femoris 
muscle;  and  in  some  instances,  though 
no  relief  is  afforded  by  the  first  issue, 
there  is  great  relief  from  the  second. 

The  good  derived  from  the  issue  does 
not  seem  to  be  in  proportion  to  the 
quantity  of  pus  discharged  from  its  sur- 
face. It  has  been  observed  by  others^ 
that  sometimes  more  abatement  of  the 
symptoms  is  produced  in  the  first  few 
days  after  the  caustic  is  applied,  and 
before  the  slough  has  separated,  than  in 
several  weeks  afterwards.  This  circum- 
stance first  led  me,  instead  of  employing 
beans  for  this  purpose,  to  keep  the  issue 
open  simply  by  rubbing  the  surface  with 
the  caustic  potash,  or  with  the  sulphate 
of  copper,  twice  or  three  times  in  the 
week^   and   after  an  extensiv^e    trial    of 


(     *71     ) 

both  methods,  the  latter  has  appeared  to 
be  decidedly  preferable  to  the  former. 
The  pain  produced  by  the  caustic  is  very 
considerable,  but  the  relief  of  the  symp- 
toms is  such,  that  I  have  known  patients 
to  be  in  the  habit  of  making  the  applica- 
tion themselves,  saying  that  "  they  knew 
they  should  be  better  by  the  next  morn- 
ing." Besides,  the  issue  is  more  easily 
dressed  than  where  beans  are  used;  and 
the  inconvenience  arising  from  the  beans 
slipping  out  under  the  adhesive  plaster, 
and  from  any  accidental  pressure  of  them 
against  the  sore  surface,  is  avoided. 

The  cases,  in  which  complete  relief  of 
the  symptoms  immediately  follows  the 
miaking  the  issue,  are  not  very  numerous. 
In  general,  there  is  some  degree  of  abate- 
ment on  the  caustic  heing  applied;  and 
in  a  few  weeks  afterwards  (provided  that 
suppuration  has  not  taken  place),  if  the 
patient  continues  in  a  state  of  quietude, 
the  pain  entirely  leaves  him.  Where  the 
pain  is  exceedingly  severe  (as  it  sometimes 


I      172     ) 

is,  so  as  to  prevent  sleep  during  many 
successive  nights),  it  is  very  desirable 
that  some  method  should  he  adopted, 
capable  of  affording  more  speedy  relief, 
than  that,  which  can  usually  be  obtained 
from  the  application  of  the  caustic.  If 
there  is  reason  to  believe  that  the  ulcer- 
ated surfaces  are  in  a  state  of  inflammation, 
in  consequence  of  the  joint  having  been 
too  much  exercised,  bleeding  may  be  had 
recourse  to.  A  blister  may  be  applied 
to  the  groin,  and  repeated  if  necessary. 
Blisters  applied  to  the  knee,  or  to  the 
thigh,  though  there  is  no  actual  disease  in 
these  parts,  will  often  occasion  consider- 
able or  even  entire  relief  of  the  pain, 
which  is  referred  to  them,  from  sympathy 
with  the  affection  of  the  hip.  This  is  a 
curious  circumstance,  but  I  have  known 
it  happen  in  so  many  instances,  that, 
however  difficult  it  may  be  to  explain  it, 
I  can  entertain  no  doubt  of  the  fact. 
Sometimes  the  pain  is  altogether  relieved 
by  the    application    of   the    blisterj    at 


(      173     ) 

other  times,  I  have  known  it  leave  the 
knee,  to  whieh  the  hlister  was  applied, 
and  attack  the  hip. 

The  objections,  which  may  be  urged 
against  the  application  of  caustic  to  the 
skin  in  the  groin,  do  not  hold  good  with 
respect  to  a  seton  in  this  situation.  I 
was  led  to  adopt  this  treatment  some 
years  ago,  partly  from  observing  that  the 
skin  of  the  groin  is  nearer  to  the  hip- 
joint,  than  the  skin  elsewhere;  partly 
from  an  expectation  (though  not  a  very 
confident  one),  that  the  making  a  seton 
over  the  trunk  of  the  anterior  crural 
nerv  e,  might  be  particularly  calculated  to 
relieve  the  pain  referred  to  those  parts, 
to  which  the  branches  of  that  nerve  are 
distributed.  The  results  of  this  practice 
more  than  realized  whatever  hopes  I  had 
entertained  of  its  success.  In  many 
cases  the  seton  occasioned  very  speedily 
a  complete  relief  of  the  pain.  In  other 
cases  indeed,  it  failed  in  producing  the 
like   good  effects;  but   these    cases   have 


(      174     ) 

borne  only  a  small  proportion  to  those  in 
which  it  has  succeeded.  On  the  whole, 
I  am  led  to  conclude,  that  where  the  pain 
is  very  severe,  the  seton  in  the  groin  is 
more  calculated  to  afford  immediate  relief 
than  the  caustic  issue;  but  that  it  is  not 
equally  efficacious  in  checking  the  pro- 
gress of  the  disease,  as  in  lessening  the 
violence  of  its  symptoms,  and  that  the 
caustic  issue  can  be  better  depended  on 
for  the  production  of  a  cure.* 

The  following  are  extracted  from  notes,  which 
were  taken  formerly,  when  I  was  making  observations 
on  this  subject. 

"November,  1808. 
"  Martha  Atkinson,  fifteen  years  of  age,  laboured 
under  symptoms  of  ulceration  of  the  cartilages  of 
the  hip.  She  had  pain  in  the  hip  and  knee,  but 
that  in  the  hip  was  the  most  severe  of  the  two.  Her 
suiferings  were  such  that  she  could  scarcely  venture 
to  make  the  slightest  alteration  in  her  position;  and 
she  could  scarcely  procure  any  rest  at  night. 

"  November  20.,  a  seton  was  made  in  the  groin. 

"  November  22.,  the  pain  in  the  hip  was  almost 
completely  relieved;  and  from  this  time  she  mended 
rapidly." 


(     175     ) 

To  make  the  seton  in  the  groin  it  is 
convenient  to  use  a  curved  seton-needle, 

"  John  Selly,  eleven  years  of  age,  was  admitted 
into  St.  George's  Hospital  on  the  28th  of  December, 
1808,  with  severe  pain  in  the  hip  and  knee;  tender- 
ness in  the  region  of  the  hip,  and  enlargement  of  the 
glands  in  the  groin. 

"  December  30.,  a  seton  was  made  in  the  groin. 

**  The  pains  in  the  hip  and  knee  were  almost  com- 
pletely relieved  within  a  few  hours  after  the  seton  was 
introduced.  The  relief  was  permanent,  and  on  the 
24th  of  May  following  he  left  the  hospital  as  cured." 

*'  Susan  Dean,  about  twelve  years  of  age,  was 
admitted  into  St.  George's  Hospital,  in  November 
1808,  with  very  severe  pains  in  the  hip  and  knee,  in 
consequence  of  disease  in  the  former  joint.  A  large 
abscess  presented  itself  on  the  upper  aiKl  outer  part 
•of  the  ^igh. 

*'  On  the  4th  of  December  a  seton  was  made  in 
the  groin.  The  pains  were  relieved  on  the  same 
afternoon.  She  had  no  return  of  pain,  while  she 
continued  in  the  hospital,  but  as  her  friends  took  her 
away  in  a  few  weeks  after  the  seton  was  made,  I  had 
no  opportunity  of  observing  the  termination  of  the 
case," 

"  James  Craven,  a  young  man,  was  admitted  ap. 
out-patient  of  St.  George's  Hospital  on  the  15th  of 
March  19P9,  with  the  usjual  symptoms  of  ulceration 


(      176      ) 

111  the  majority  of  cases,  the  patient  keeps 
the  thigh  considerably  bent  on  the  pel- 
vis; and  this  position  of  the  limb  makes 
it  difficult  to  employ  a  needle  of  the 
usual  form.  The  seton  may  be  intro- 
duced obliquely  on  the  anterior  part  of 
the  joint;  including  from  one  inch  and  a 
half  to  two  inches  of  integuments.  After 
some  time  the  skin  over  it  usually  inflames 
and  ulcerates,  and  the  seton  drops  out; 
but  this  does  not  happen  before  it  has 
produced  all  the  benefit  which  may  be 
expected  from  it. 


of  the  cartilages  of  the  hip.  There  was  a  large 
abscess  on  the  outside  of  the  thigh,  and  intense  pain 
in  the  knee  preventing  his  rest  at  night. 

"  March  16.,  a  seton  was  made  in  the  groin. 
Being  unable  to  become  an  in-patient  of  the  hospi- 
tal, he  walked  home  afterwards.  Nevertheless  the 
pain  was  completely  relieved  in  a  few  hours:  and  he 
slept  soundly  at  night,  the  pain  not  at  all  disturbing 
him. 

"  After  this  the  abscess  burst,  and  collected  again 
several  times;  and  he  became  affected  with  hectic 
symptoms.  I  did  not  see  the  termination  of  the 
case,  but  I  make  no  doubtof  it  having  ended  fatally/' 


(      177     ) 

Of  the  above  observations  on  tbe  uU 
eeration  of  the  cartilages  of  tlie  hip, 
many  arc  applicable  to  the  disease  in 
other  joints.  In  all  cases,  a  state  of  the 
most  perfect  quietude  is  indispensable. 
If  the  disease  be  in  the  lower  extre- 
mity, the  patient  should  be  confined  to 
the  horizontal  position;  if  in  the  upper, 
the  arm  should  be  supported  in  a 
sling.  Where  the  knee  or  elbow  is 
affected,  we  may  employ  the  caustic 
issue,  or  the  blister  kept  open  by  means  of 
the  savine  cerate,  but  the  former  appears 
to  be  the  most  efficacious  of  the  two. 
In  the  knee,  a  narrow  slough  may  be 
made  by  rubbing  the  skin  with  the 
potassa  fiisa  on  each  side  of  the  patella; 
and,  in  the  elboAV,  the  caustic  nvAj  be 
applied  in  the  same  manner  on  the  in- 
side, and  on  the  outside  of  the  joint. 
When  I  have  met  with  this  disease  in 
the  shoulder,  I  have  sometimes  employed 
a  large  blister,  and  kept  it  open  by  means 
of  the  savine  cerate;  and  in  other  cases  J 
24 


(     178     ) 

have  made  two  caustic  issues,  one  on  the 
anterior,  the  other  on  the  posterior  part 
of  the  joint;  and,  on  the  whole,  the 
caustic  issues  have  appeared  to  be  pro- 
ductive of  better  effects  than  the  blister. 
Where  the  disease  has  its  seat  in  those 
joints,  which  are  surrounded  by  numerous 
tendons,  as  the  wrist  and  ankle,  it  may  be 
more  prudent  to  employ  the  blister,  lest 
injury  should  be  done  to  the  superficial 
tendons  by  the  application  of  the  caustic. 
I  have,  however,  in  a  few  cases,  made  a 
caustic  issue  below  the  internal  or  exter- 
nal malleolus.  It  has  produced  the  best 
effects  with  respect  to  the  disease  in  the 
ankle,  but  has  been  attended  Avith  unusual 
irritation  and  distress  to  the  patient,  so 
that  it  was  with  difficulty  that  he  could 
be  induced  to  allow  it  to  be  kept  open 
for  a  sufficient  length  of  time. 

I  have  seen  scAcral  cases,  which  the 
cr^Qstic  issue  has  in  the  first  instance  re- 
moved all  symptoms  of  the  disease, 
and  yet  after  some   time,   notwithstand- 


(      179      ) 

ing  the  patient  has  remained  in  a  state 
of  perfect  quietude,  and  there  has  heen 
no  evident  cause  of  aggravation,  they 
have  returned  nearly  in  the  same  form 
as  hefore,  and  with  their  original  severity. 
In  some  of  these  cases,  their  recurrence 
is  to  he  attrihuted  to  the  issue  itself; 
which  from  some  cause,  that  the  present 
state  of  our  knowledge  does  not  enable 
us  to  explain,  prqduces  an  effect,  appa- 
rentl}^  the  opposite  to  that,  which  is  pro- 
duced when  it  was  first  made.  The  issue 
being  allowed  to  heal,  the  symptoms  again 
subside,  and  perhaps  the  patient  may 
find  himself  entirely  and  permanently  re- 
lieved before  the  sore  is  completely  cica- 
trized. The  same  thing  may  be  observed, 
perhaps  more  frequently,  where  a  blister 
has  been  long  kept  open  by  means  of  the 
savine  cerate;  and  here,  if  the  blister  be. 
of  a  large  size,  the  recurrence  of  the  pain 
is  usually  attended  with  a  quick  pulse,  and 
a  furred  tongue,  and  much  constitutionj^l 
irritation,  of  all  which   the  patient  is  re- 


(      180     ) 

iicvcd,  when  the  hlistered  surface  is  al- 
lowed  to  skin  over.  It  is  evident  that  it 
is  of  much  importance,  and  also  that  it 
may  require  considerable  discrimination 
on  the  part  of  the  surgeon,  to  distinguish 
when  the  issue  or  the  blister  begins  to  be 
injurious,  and  ought  therefore  to  be  per- 
severed in  no  Ion  O'er. 

In  other  instances,  where  the  symp- 
toms have  returned  under  the  use  of  the 
caustic  issue,  it  has  appeared  to  me  that 
this  was  to  be  explained  in  a  different 
manner.  A  very  small  quantity  of  matter 
has  been  formed  by  the  ulcerated  sur- 
faces of  the  joint,  but  not  suificient  to 
prevent  the  iipplication  of  the  caustic 
from  producing  in  the  first  instance  Acry 
considerable  benefit.  But  having  once 
begun,  the  suppuration  has  continued, 
luitil  a  sufficient  quantity  of  pus  has  been 
collected  to  occasion  distention  of  the 
joint,  and  the  reproduction  of  the  former 
symptoms,  in  spite  of  the  remedy,  which 
before   relieved    them.     Such   cases    are 


(      181      ) 

^lot  of  very  im frequent  occurrence,  and 
they  shew  tliat  the  surgeon  should  not 
incautiously  give  a  very  favourable  pro- 
gnosis in  the  iirst  instance,  because  the 
immediate  effects  of  the  issue  have  been 
beneficial;  but  that  he  should  wait  and  ob- 
serve, whether  these  good  effects  continue, 
before  he  ventures  positively  to  predict 
his  patient's  recovery. 


The  treatment  of  the  abscess,  which 
arises  from  this  disease  in  a  joint,  makes 
a  question  of  very  serious  importance,  but 
more  so  as  it  regards  children,  than 
adults;  since  the  former  may,  and  do 
frequently,  recover,  even  after  an  exten- 
sive suppuration  has  taken  place;  whereas. 
this  is  a  very  rare  occurrence  in  a  grow  n- 


n 


p  person 


* 


-*  It  is  to  be  observed  that  I  speak  here  only  of  the 
abscess  in  a  joint,  v^hich  is  the  consequence  of  ulcer- 
ation of  the  cartilage  occurring  as  a  primary  disease. 


(      i«2      ) 

1  have  not  found  that  the  method  of 
evacuating  the  matter,  which  has  heen 
recommended  by  Mr.  Abernethy,  in  his 
treatise  on  the  lumbar  abscess,  is  attended 
with  any  particular  advantage  in  a  case  of 
carious  joint.  Indeed  this  corresponds 
with  what  a  little  consideration  might 
lead  us  to  expect.  If  an  abscess  takes 
place  as  a  primary  aftection,  the  disease 
being  confined  to  the  soft  parts,  there  may 
be  nothing  to  prevent  the  contraction  of 
tlie  cyst,  and  gradual  diminution  of  the 
quantity  of  pus  evacuated  at  each  punc- 
ture. But  where  an  abscess  occurs,  in 
consequence  of  an  ulcerated  state  of  the 
articular  cartilages  and  bones,  as  the 
cause  of  the  abscess  exists  equally  after, 
as  before  the  puncture,  the  suppuration 
will  necessarily  be  kept  up,  and  the  con- 
traction of  the  cyst,  and  the  obliteration 
of  its  cavity,  will  be  prevented. 

In  some  instances  I  have  been  led  to 
believe,  that,  after  the  application  of  the 
caustic,  the  tumor  formed  b}  the  abscess 


(      ^S3      ) 

lias  diminislied  in  size,  as  if  from  an  ab- 
sorption of  a  portion  of  its  contents.  I 
have  however  seen  no  instance  of  com- 
plete absorption  haying  taken  place, 
though  I  have  made  vai'ious  attempts  to 
produce  so  desirable  an  effect.  Emetics, 
whether  they  were  given  to  excite  vomit- 
ing, or  only  in  nauseating  doses,  were,  in 
my  experiments,  of  no  service.  Electricity 
was  never  useful;  appearing  rather  to 
occasion  a  more  rapid  accumulation  of 
matter.  Knowing  that  pressure,  under 
certain  circumstances,  causes  an  increased 
action  of  the  absorbent  vessels,  in  tv>o 
cases  I  applied  stripes  of  adhesive  plaster 
round  the  limb,  with  the  view  of  trying 
the  effects  of  pressure  on  the  contents  of 
the  abscess.  The  consequence  was  a 
speedy  diminution  of  the  external  tumor; 
but  1  afterwards  found  that  this  arose, 
not  from  any  absorption  having  taken 
place,  but  simply  from  the  increased  re- 
sistance on  the  surface  causing  the  abscess 


(      184      ) 

to  occupy  a  larger  space  in  the  interioi*  of 
the  Jimb. 

The  earl}'  puncture  ot*  an  abscess  con- 
nected with  a  diseased  joint  is  certainly 
not  to  be  recommended.  I  have  always 
observed  that  such  an  abscess  has  healed 
more  readily,  and  that  the  opening  of  it, 
(whether  by  a  natural  process,  or  by  the 
lancet,)  has  been  attended  with  fewer  ill 
consecjuences,  where  the  patient  has  been 
kept  for  some  time  in  a  state  of  perfect 
quietude,  and  the  other  methods  of 
treatment,  formerly  mentioned,  have  been 
previously  resorted  to,  than  where  it  has 
taken  place  immediately  on  the  patient 
comins:  under  the  care  of  the  sursceon. 
Nor  is  this  difficult  to  explain:  in  the 
latter  case,  at  the  bottom  of  the  abscess 
there  is  a  carious  oi*  ulcerated  surface  of 
bone;  in  the  former,  it  is  highly  probable 
that  the  process  of  cure  has  already  be- 
gun, and  that  where  there  was  diseased 
bone  before,  there  is  now  a  granulating 
surface.     At  any  rate  it  cannot  be  sup. 


(      185      ) 

posed,  that  when,  in  consequence  of  the 
neglect  of  the  disease,  the  ulcerated  bones 
as  well  as  the  other  parts,  are  in  a  state  of 
inflammation,  the  abscess  can  be  under 
such  favourable  circumstances  for  beina: 
opened,  as  when  such  inflammation  has 
been  previously  allowed  to  subside,  under 
rest,  and  the  employment  of  proper  re- 
medies. 

An  abscess  connected  with  any  joint, 
but  particularly  one  connected  with  the 
hip,  does  not  form  a  regular  cavity,  but 
usually  makes  numerous  and  circuitous 
sinuses,  in  the  interstices  of  the  muscles, 
tendons,  and  fascise,  before  it  presents 
itself  under  the  integuments.  It  is  there- 
fore less  easy  to  evacuate  its  contents, 
than  those  of  an  ordinary  lumbar  abscess; 
and  indeed  it  can  seldom  be  emptied, 
without  handling  and  compressing  the 
limb,  in  order  to  press  the  matter  out  of 
the  sinuses,  in  which  it  lodges.  But  this 
is  often  attended  with  very  ill  conse- 
4j[uences.      Inflammation  takes  place   of 

25 


(     186     ) 

the  cyst  of  the  abscess,  and  pus  is  again 
very  rapidly  accumulated.  Small  blood- 
vessels give  way  on  its  inner  surface,  the 
bloody  discharge  of  wliich,  mixed  with 
the  newly-secreted  pus,  goes  into  putre- 
faction, and  exceedingly  irritates  the  ge- 
neral system.  I  have  seen  cases,  where, 
after  a  great  deal  of  pains  having  been 
taken  to  obtain  the  complete  evacuation 
of  the  contents  of  the  abscess,  and  the 
puncture  having  healed,  in  a  few  days  the 
tumor  has  become  as  large  as  ever,  at- 
tended with  pain  in  the  limb,  and  a  fever 
resembling  typhus  in  its  character,  and 
threatening  the  life  of  the  patient.  A 
second  puncture  having  been  made,  a 
quantity  of  putrid  foetid  ,pus,  of  a  reddish 
brown  colour,  has  escaped;  the  confine- 
ment of  which  had  produced  all  the  bad 
sym2)toms,  which  have  been  immediately 
relieved  by  its  evacuation. 

The  practice,  which  has  4appeared  to 
me  to  be,  on  the  whole,  the  best,  is  the 
following.   An  opening  having  been  made 


(     187     ) 

witli  an  abscess  lancet,  the  limb  may  be 
wrapped  up  in  a  flannel  wrung  out  of  hot 
water,  and  this  may  be  continued,  as  long 
as  the  matter  continues  to  flow  of  itself. 
In  general,  when  a  certain  quantity  has 
escaped  the  discharge  ceases;  the  orifice 
heals,  and  the  puncture  may  then  be  re- 
peated some  time  afterwards;  but  where 
the  puncture  has  not  become  closed, 
I  have  seldom  found  any  ill  consequences 
to  arise  from  it  remaining  open. 

I  have  already  observed  that  the  pro- 
gnosis, which  the  surgeon  is  led  to  form, 
must  depend  very  much  on  the  circum- 
stance of  suppuration  having,  or  not  hav- 
ing taken  place.  The  formation  of  even 
the  smallest  quantity  of  pus  in  the  joint, 
in  cases  of  this  disease,  in  the  young  per- 
son considerably  diminishes,  and  in  the 
adult  very  nearly  precludes,  the  possibility 
of  any  ultimate  good  being  derived,  except 
from  amputation.  On  the  other  hand, 
where  abscess  has  not   bescun   to  form. 


I      188      ) 

there  is  perhaps  no  disease,  anjoiig  those 
which  come  tinder  the  care  of  the  surgeon, 
in  which  he  can  eniploy  his  art,  with  a 
better  prospect  of  success  than  this.  It  is 
to  he  observed  however  that  the  symp- 
toms may  be  relieved,  while  there  are 
still  some  remains  of  the  disease:  or,  at 
any  rate,  while  there  is  still  a  disposition 
to  relapse;  and  in  order  that  the  cure 
should  be  permanent,  it  is  necessary  that 
the  treatment  should  be  employed  for 
some  tim^  after  the  patient  is  apparently 
recovered.  xV  gentleman  who  had  long 
laboured  under  ulceration  of  the  cartilages 
of  the  hip,  finding  himself  to  be  free 
from  all  uneasiness,  allowed  the  issue  to 
be  healed.  This  was  attended  with  no 
immediate  ill  consequences;  but  in  the 
course  of  two  or  three  months  he  began 
to  experience  the  well-known  symptoms 
of  his  former  complaint.  A  caustic  issue 
was  again  made,  and  he  was  again  re- 
lieved.     The   issue   was   kept  open  for 


(     1«9      ) 

twelve  months  longer  and  then  liealed. 
When  I  last  saw  him,  two  or  tliree  years 
after  the  healing  of  the  issue,  he  continued 
perfectly  well.  This  however  is  only  one 
of  many  cases,  which  might  be  quoted  in 
proof  of  the  above  observation. 


When  the  ulceration  of  the  cartilages 
has  made  very  considerable  progress,  if 
the  patient  recovers,  so  as  to  preserve  the 
limb,  he  seldom  has  the  use  of  the  joint 
afterwards,  the  bones  composing  it  being 
united  by  anchylosis;  but  if  it  has  been 
checked  in  a  less  advanced  stage,  even 
though ,  there  is  reason  to  believe  that 
the  cartilages  have  been  extensively  de- 
stroyed, the  patient  may  retain  the  na- 
tural motion  of  the  joint.  I  have  not 
Iiitherto  examined  any  cases,  in  which  it 
appeared,  that  there  had  been  an  attempt 
at  tlie  regeneration  of  the  absorbed  car- 
tilages:   and    I    have    occasionally   been 


(      190      ) 

'able  bo  til  to  feel  and  to  hear  the  hard 
surfaces  of  the  bones  grating  against 
each  other  in  the  motion  of  the  joint,  in 
such  a  manner  that  it  was  evident  that 
they  had  no  cartilaginous  coverings.  In 
some  instances  a  compact  layer  of  bone 
is  formed  on  the  carious  surface,  nearly 
similar  to  what  is  seen  in  the  healthy 
bone,  after  the  cartilage  has  been  de- 
stroyed by  maceration.  I  have  many 
times,  in  dissection,  observed  a  portion 
of  the  cartilage  of  a  joint  wanting,  and 
in  its  place,  a  thin  layer  of  hard, 
semi-transparent  substance,  of  a  grey 
colour,  and  presenting  an  irregular  gra- 
nulated surface.  It  is  probable  that  in 
these  cases,  the  original  disease  had  been 
ulceration  of  the  cartilages.  In  a  subject 
in  the  dissecting  room,  I  found  no  re- 
mains of  cartilage  on  the  bones  of  one 
hip;  but  in  its  place,  a  crust  of  bony 
matter  was  formed,  of  a  compact  texture, 
of  a  white  colour,  smooth,  and  having 
an  appearance  not  very  unlike  that  of 


(      191      ) 

marble.  I  suspected  tins  also  to  have 
been  a  case,  in  which  the  patient  had  re- 
covered, after  ulceration  of  the  cartilage; 
and  this  opinion  was  rendered  more  pro- 
bable, by  the  following  case,  which  after- 
wards occurred. 


CASE  XXXIV* 

A  woman,  thirty-six  years  of  age,  was 
admitted  into  St.  George's  Hospital,  with 
pain  in  the  hip  and  knee  on  one  side. 
The  nates  were  wasted  and  flattened, 
and  a  large  abscess  had  burst,  leaving  a 
sinus  communicating  with  the  hip-joint. 
She  was  affected  with  hectic  fever,  and 
gradually  sunk  and  died. 

On  inspecting  the  body,  various  sinuses 
were  found  in  the  neighbourhood  of  the 
hip  and  communicating  with  it. 

The  synovial  membrane  and  capsular 
ligament  had  undergone  no  alteration  in 
their  appearance,  beyond  what  evidently 


(      192      ) 

depended  on  the  abscess.  The  cartilage 
was  every  where  absorbed  from  the  arti- 
culating surfaces,  and  in  its  place  there 
was  a  white  polished  surface,  similar  to 
that,  which  has  been  just  described. 


Sect.  IV. 

Cases  of  this  Disease. 

The  following  cases,  which  are  taken 
from  many  similar,  of  which  I  have  pre- 
served notes,  are  intended  to  illustrate 
the  observations,  contained  in  the  two 
last  sections.  There  seems  to  be  no 
doubt  that  the  disease  was  ulceration  of 
the  articular  cartilages,  since  the  symp- 
toms exactly  corresponded  with  those, 
which  have  been  observed  in  cases  of 
this  description,  in  which  an  opportunity 
occurred  of  examining  the  morbid  ap- 
pearances after  death,  or  after  ampu- 
tation. It  will  be  observed  that  I  have  not 
selected  cases,  in  which  the  disease  was 


(     193     ) 

situated  in  the  liip:  nor,  in  which  it  liad 
reached  its  most  advanced  stages:  my 
reasons  for  which  have  heen,  that  a  suffi- 
cient number  of  examples  of  this  affec- 
tion of  the  hip,  may  he  found  among  the 
cases  already  published  by  Mr.  Ford,  and 
other  writers:  and  that  it  is  in  the  early 
stage  of  the  disease  that  it  principally 
deserves  to  be  studied,  and  that  the 
diagnosis  is  of  the  most  importance. 

CASE  XXXV. 

Mary  Jenkins,  twenty-one  years  of  age, 
in  May,  1809,  received  a  blow  on  one 
of  her  knees.  Soon  afterwards  she  was 
seized  with  pain  in  the  joint,  which  gra- 
dually became  more  severe.  In  Septem- 
ber of  the  same  year,  she  was  admitted 
into  St.  George's  Hospital,  on  account  of 
this,  and  of  some  other  complaints, 
which  required  medical  treatment.  At 
first  she  was  under  the  care  of  Dr.  Ban- 
croft.     On  the  9th   of  November,   she 

26 


(     1^4     ) 

came  under  the  care  of  the  surgeons. 
At  this  time,  the  knee  was  somewhat 
swollen;  the  swelling  having  the  form  of 
the  articulating  ends  of  the  bones,  and 
appearing  greater  than  it  really  was,  on 
account  of  the  wasting  of  the  muscles  of 
the  limb.  No  fluid  was  perceptible  in 
the  joint.  She  complained  of  violent 
pain,  which  she  referred  chiefly  to  the 
inside  of  the  bead  of  the  tibia,  and  which 
was  extremely  aggravated  by  motion. 
There  was  no  redness  of  the  skin.  She 
was  emaciated,  and  laboured  under  a 
slight  degree  of  hectic  fever. 

An  issue  was  made  with  caustic  on 
each  side  of  the  ligament  of  the  patella. 
The  issues  were  kept  open  by  means  of 
peas:  their  surfaces  being  also  rubbed 
with  caustic  every  fourth  day. 

At  the  expiration  of  a  fortnight  the 
pain  was  very  much  abated:  she  was 
able  to  give  some  motion  to  the  joint 
without  much  uneasiness.  The  swelling 
had  nearly  disappeared. 


(      195     ) 

In  a  short  time  the  pain  was  com- 
pletely relieved;  however  she  did  not 
quit  the  hospital  until  the  September  of 
the  following  year.  At  this  time  she  was 
free  from  all  had  symptoms,  and  had  re- 
covered the  perfect  use  of  the  joint. 

CASE  XXXVI. 

John  Reade,  twenty-eiglit  years  of  age, 
applied  for  relief  as  an  out-patient  of  St. 
George's  Hospital  on  the  4th  of  October, 
1811. 

He  said,  that  for  two  years  preceding 
he  had  been  subject  to  pains  in  the  elbow, 
which  were  occasionally  severe,  but  at- 
tended with  little  or  no  swelling.  At 
the  time  of  his  coming  to  the  hospital, 
the  pain  in  the  joint  was  very  violent, 
particularly  at  night,  when  it  continually 
roused  him  from  his  sleep.  There  was 
also  pain  in  the  shoulder  and  wrist,  but 
trifling,  Avhen  compared  to  that  in  the 
elbow,  and  only  occasional.     The  elbow 


(      196     ) 

was  slightly  swollen,  the  swelling  hav- 
ing the  fornn  of  the  articulating  ends 
of  the  hones,  and  arising,  not  from 
fluid  within  the  joint,  but  from  inflam- 
mation having  extended  to  the  cellular 
membrane  external  to  it.  The  fore-arm 
was  kept  bent,  and  all  attempts  to  move 
it  from  this  position  caused  a  severe  ag- 
gravation of  the  symptoms.  There  was 
some  degree  of  symptomatic  fever. 

Eight  ounces  of  blood  were  taken  from 
the  other  arm,  whicli  occasioned  some,  but 
not  considerable  relief. 

October  8th.  A  caustic  issue  was  made 
on  each  side  of  the  joint. 

October  11th.  He  was  free  from  the 
symptomatic  fever;  the  pain  in  tlie  shoul- 
der and  wrist  had  entirely  left  him;  that 
in  ^he  elbow  was  much  diminished. 

October  19th.  The  sloughs  were  se- 
parated. The  issues  were  afterwards  kept 
open  by  the  occasional  application  of 
caustic.  He  now  made  very  little  com- 
plaint  of  pain,  and   slept  well  at  night. 


(      197      ) 

From  tliis  time  be  experienced  very  little 
uneasiness.  He  gradually  recovered  the 
use  of  the  elbow;  and  in  a  few  weeks, 
findins:  no  inconvenience  from  tbe  com- 
plaint,  be  ceased  to  attend  at  tbe  bospital. 

CASE  XXXVIT. 

Anne  Wbite,  twenty-one  years  of  age, 
was  admitted  into  St.  George's  Hospital, 
on  tbe  8tb  of  January,  1814. 

Sbe  said,  tbat  tbree  montbs  before  lier 
admission  sbe  was  seized  witb  pain  of  tbe 
left  knee.  Tbe  pain  was  sligbt  at  first, 
but  gradually  increased  in  violence.  In 
less  tbaii  a  montb  after  tbe  pain  first  at- 
tacked ber,  tbe  joint  became  sligbtly 
swollen.  About  a  fortniacbt  before  ber 
admission,  slie  was  seized  with  a  pain  in 
ber  left  elbow  unattended  by  swelling. 

At  tbe  time  of  ber  applying  at  tbe 
hospital,  tbe  knee  was  swollen,  but 
only  in  a  sligbt  degree.  Tbe  swelling 
had  tbe  form  of  the  bones  of  tbe  joint. 


C      198      ) 

arising  from  an  effusion  into  the  cellular 
texture,  and  not  from  fluid  within  the 
synovial  memhrane. 

During  the  day  she  had  violent,  but  not 
constant  pain  in  the  kneej  the  pain  attack- 
ing her  by  fits,  which  lasted  a  few  minutes. 
During  the  night,  the  pain  was  more  con- 
stant, and  very  severe,  so  as  to  disturb 
her  rest  exceedingly.  The  pain,  when 
most  violent,  extended  up  the  thigh  and 
down  the  leg.  The  joint  was  capable  of 
motion,  but  all  motion  aggravated  the  pain 
There  was  great  tenderness  on  the  in- 
side of  the  knee.  The  skin  was  somewhat 
redder  than  natural,  but  the  redness  was 
greater  at  one  period  than  at  another. 

She  complained  also  of  pain  in  the  el- 
bow, extending  up  the  arm  and  down  the 
fore-arm.  This  joint  was  not  at  all  swol- 
len. She  had  lost  flesh:  had  a  white 
tongue,  quick  small  pulse,  and  was  occa- 
sionally flushed. 

Immediately  on  her  admission  leeches 
were  applied  to  the  knee,  which   some- 


;  (   199  ) 

what  relieved  the  pain  in  this  joint.  On 
the  nth  of  January  a  caustic  issue  was 
made  on  each  side  of  the  elhow:  and  on 
the  13th  of  January  an  issue  was  made  on 
each  side  of  the  knee. 

On  the  17th  of  January  the  pain  in  the 
elbow  was  almost  completely  relieved: 
that  in  the  knee  was  somewhat  less. 

The  issues  were  kept  open  hy  the  occa- 
sional application  of  caustic.  The  pain 
and  swelling  of  the  knee  gradually  sub- 
sided, and  she  recovered  her  health. 
The  issues  were  not  healed  until  the  end 
of  May,  at  which  time  the  swelling  of  the 
knee  had  subsided,  and  there  was  no 
pain  either  of  the  knee  or  elbow. 

CASE  XXXVIII. 

A  gentleman,  twenty-four  years  of  age, 
about  the  end  of  the  year  1816,  became 
affected  with  a  slight  pain  in  the  left 
ankle;  and  he  observed  also  that  this  pain 
was  particularly  aggravated,  whenever  any 


(      200      ) 

thing  occurred  to  press  the  articulating 
surfaces  of  the  joint  against  each  other; 
for  example,  when  he  happened  to  tread 
with  his  heel  on  any  projecting  stone  in 
the  street.  He  also  observed  a  very  slight 
degree  of  puffy  swelling  on  the  anterior 
and  outer  part  of  the  joint,  before  the 
external  malleolus. 

On  the  6th  of  January,  1817,  he  went 
to  a  ball  and  danced;  and  on  the  follow- 
ing day  the  pain  was  very  much  aggra- 
vated. The  exercise  also  brought  on 
some  degree  of  general  tumefaction  about 
the  joint,  which  however  subsided  with 
rest,  in  the  course  of  twenty-four  hours. 
But  the  pain  continued  and  increased; 
so  that  he  could  not  support  the  weight 
of  his  body  on  that  foot,  and  he  was  com- 
pelled to  walk  with  the  assistance  of  one, 
and  afterwards  of  two  sticks.  In  May  fol- 
lowing, a  general  puffy  swelling  took  place 
round  the  whole  joint,  which  did  not 
subside. 


(     201      ) 

On  the  SOtliof  June,  1817,  he  consulted 
me,  being  then  in  the  following  condition. 

There  was  some  degree  of  general 
cedematous  tumefaction  of  the  whole 
joint,  in  consequence  of  slight  inflamma- 
tion of  the  cellular  membrane  external 
to  it.  There  was  a  constant  and  severe 
pain  referred  to  the  ankle,  which  was 
rendered  more  violent,  when  he  attempted 
to  stand,  and  when  the  cartilaginous  sur- 
faces were  pressed  against  each  other,  by 
the  hand  placed  on  the  lower  part  of  the 
heel.  His  rest  was  disturbed  at  night,  by 
painful  startings  of  the  limb. 

He  had  come  to  consult  me  at  my  own 
house,  and  in  going  home,  he  fell  from 
his  horse,  and  wrenched  his  ankle,  which 
brought  on  inflammation,  and  rendered 
all  the  symptoms  still  more  severe. 

He  was  directed  to  remain  at  home,  in 
a  state  of  perfect  quietude,  and  never  to 
place  the  foot  on  the  ground.  Leeches 
and  cold  lotions  were  ap^^lied,  and  the 
leeches  were  repeated.    Under  this  treat- 

27 


(      202      ) 

ment  the  additional  inflammation  induced 
by  the  accident  subsided;  and  the  pain 
became  much  less  severe.  At  the  end  of 
August,  a  blister  was  applied  on  each  side 
of  the  ankle,  and  kept  open  by  means  of 
the  saline  cerate.  After  the  first  blisters 
were  healed,  others  were  applied,  and 
kept  open  in  the  same  manner,  and  in 
the  intervals  between  the  applications  of 
the  blisters  the  joint  was  bound  up  in 
stripes  of  linen  spread  with  soap  cerate 
plaster. 

About  the  end  of  September  he  was  so 
much  relieved  that  (having  some  con- 
cerns which  it  wa^  of  much  importance  to 
himself  to  attend  to,)  he  was  allowed  to 
go  out  occasionally  in  a  chaise. 

On  the  20th  of  December,  a  caustic 
issue  was  made  behind  the  inner  ankle. 
This  occasioned  exceeding  irritation  and 
uneasiness,  and  the  issue  was  in  conse- 
quence allowed  to  begin  to  heal,  about  a 
fortnight  after  the  separation  of  the 
slough.   He  was  how^jver  much  benefited 


(      203     ) 

hy  the  issue;  and  after  it  was  healed,  he 
was  free  from  pain,  and  the  swelling  had 
subsided. 

On  the  23d  of  May,  1818,  he  was  in 
the  following  condition.  He  was  free 
from  all  pain;  could  bear  the  joint  to  be 
moved,  and  could  support  the  weight  of 
the  body  on  that  foot  without  inconveni- 
ence. There  were  still  some  slight  re- 
mains of  the  external  swelling.  When 
the  joint  was  moved,  a  grating  sound 
could  be  heard;  and  if  at  this  time  the 
fingers  were  applied  to  the  joint,  a  sen- 
sation was  communicated  to  them,  as  if 
two  hard  and  rough  surfaces  were  rubbed 
one  against  the  other. 

CASE  XXXIX. 

Mary  Taylor,  fifty  years  of  age,  was  ad- 
mitted into  St.  George's  Hospital,  on  the 
3d  of  December,  1809. 

She  said,  that  in  the  preceding  July 
she  had  a  violent  wrench  of  the  right 


(     204     ) 

shoulder,  in  consequence  of  her  husband 
having  pulled  her  by  the  arm.  Soon 
afterwards  she  was  attacked  with  pain 
in  this  joint,  which  gradually  became 
very  severe.  At  the  time  of  her  admission 
into  the  hospital,  there  was  no  alteration 
in  the  external  appearance  of  the  shoulder. 
There  was  not  the  smallest  evident  swell- 
ing; but  she  complained  of  constant  and 
violent  pain,  which  was  much  aggravated 
by  every  attempt  to  move  the  arm.  The 
pain  w  as  most  severe  at  night,  so  as  very 
much  to  disturb  her  rest.  She  was  unable 
to  lie  on  the  side,  on  which  the  disease 
was  situated. 

The  arm  was  supported  by  a  sling,  and 
a  blister  was  applied  to  the  shoulder,  and 
afterwards  kept  open  by  means  of  savine 
cerate. 

In  less  than  a  fortnight  the  symptoms 
were  much  relieved.  In  the  beginning 
of  January,  1810,  she  had  very  little  pain, 
and  slept  well  at  night.  About  the  middle 
of  February  she  was  dismissed  from  the 


(      205      ) 

hospital,  being  free  from  all  her  former 
symptoms.  She  was  directed  to  attend 
as  an  out-patient,  that  the  blister  might 
be  kept  open  for  some  time  longer;  how- 
ever she  never  made  her  appearance  at 
the  hospital  again,  probably  in  conse- 
quence of  her  finding  no  inconvenience 
from  the  complaint,  and  of  her  not  being 
convinced  of  the  necessity  of  continuing 
the  treatment  after  the  symptoms  were 
relieved. 


I  have  before  observed  that  ulceration 
of  the  articular  cartilages  is  not  unfre- 
quently  complicated  Avith  inflammation 
of  the  synovial  membrane.  Sometimes 
the  one,  and  sometimes  the  other  is  the 
original  disease,  in  like  manner  as  we 
find  ulcer  of  the  cornea  of  the  eye  in  some 
cases  the  cause,  and  in  others  the  con- 
sequence, of  inflammation  of  the  tunica 
conjunctiva.  In  the  very  advanced  stage, 
when   the   organization   of  the  joint  is 


(      206      ) 

completely  destroyed,  this  complication 
must  always  exist:  and  it  is  unnecessary 
to  adduce  evidence  of  this  fact.  But 
occasionally  the  two  diseases  are  com- 
bined together  in  a  more  early  stage, 
and  previous  to  the  establishment  of 
suppuration. 

In  the  following  case,  which  is  related 
for  the  purpose  of  illustrating  this  sub- 
ject, ulceration  of  the  cartilage  appears 
to  have  been  the  primary,  and  inflam- 
mation of  the  synovial  membrane  the 
secondary  affection:  at  least  the  symp- 
toms which  occurred  are  better  expli- 
cable on  this  supposition  than  on  any 
other. 

CASE  XL. 

John  Child,  thirty-three  years  of  age, 
in  April,  1814,  was  seized  with  a  pain  in 
one  knee,  the  pain  at  first  was  slight,  but 
gradually  became  very  severe.  It  was 
referred  principally  to  the  head  of  the 


(     207      ) 

tibia  on  each  side  of  the  ligament  of  the 
patella.  At  the  end  of  five  months, 
the  joint  for  the  first  time  became 
swollen,  and  the  swelling  soon  attained 
a  considerable  size.  He  was  now  un- 
der the  necessity  of  confining  himself 
to  his  room.  Five  blisters  were  applied 
in  succession,  and  the  swelling  and  pain 
subsided,  so  that  at  the  end  of  three 
weeks  he  returned  to  his  usual  occu- 
pations. In  five  or  six  days  however 
the  pain  and  the  swelling  returned,  and 
he  was  in  consequence  admitted  into 
St.  George's  Hospital  on  the  26th  of 
October. 

At  this  time  he  complained  of  pain  in 
the  joint,  referred  to  the  head  of  the  tibia, 
on  each  side  of  the  ligament  of  the  patella. 
The  pain  was  excruciating,  so  as  often 
to  keep  him  awake  during  the  whole 
night.  The  knee  was  much  swollen: 
the  swelling  arising  from  an  eff^usion  of 
fluid  into  its  cavity,  and  having  the  same 
form  as  in  ordinary  cases  of  inflammation 
of  the  synovial  membrane. 


(      208      ) 

October  29.  A  blister  was  applied  in- 
cluding tbe  greater  part  of  tbe  circumfer- 
ence of  the  joint. 

IN^ovember  6.  The  swelling  and  pain 
were  relieved.  Another  blister  was  ap- 
plied, which  was  kept  open  with  the 
savine  cerate  until  the  end  of  the  month. 
It  was  then  healed,  and  a  thii'd  blister 
was  applied  and  kept  open  in  the  same 
manner. 

On  the  21st  of  December  he  left  the 
hospital  of  his  own  accord.  The  pain  at 
this  time  was  very  nearly,  but  not  com- 
pletely relieved:  the  knee  was  swollen 
only  in  a  very  slight  degree,  and  the  tri- 
fling swelling,  which  remained,  appeared 
to  arise  not  from  fluid  within  the  articu- 
lation, but  from  thickening  of  the  soft 
parts  in  consequence  of  their  having  been 
previously  inflamed. 


CHAP.  y. 

ON  A  SCROPHULOUS  DISEASE  OF  THE  JOINTS 
HAVING  ITS  ORIGIN  IN  THE  CANCELLOUS 
STRUCTURE  OF  THE  BONES. 


Sect.  I. 
Patholomcal  Observations. 


'3' 


The  term  scrophula  is  often  employed 
without  much  precision;  and  indeed  it  is 
not  always  easy  to  determine,  what  symp- 
toms ought,  and  what  ought  not,  to  he 
referred  to  this  disease.  It  has  been 
usual  to  regard  nearly  all  the  affections 
of  the  joints  as  scrophulous;  and  I  believe 
it  may  be  found  that  persons  having  a  pre- 
disposition to  scrophula  are  on  the  whole 
more  liable  than  others,  to  those  af- 
fections, which  form  the  subject  of  the 
28 


(     210     ) 

preceding  chapters.  As  however  they 
occur  very  frequently,  where  no  such 
predisposition  exists,  there  seem  to  he  no 
sufficient  grounds  for  considering  them  as 
having  any  necessary  connection  with  it: 
and  it  can  be  no  more  proper  to  designate 
these  as  scrophulous,  than  it  would  he  to 
denominate  inflammation  of  the  synovial 
membrane  a  mercurial  disease,  because  it 
occasionally  arises  from  the  use  of  mercury. 
But  there  is  another  maladv,  which  affects 
the  joints,  having  all  the  characters  of 
scrophula:  generally  occurring  in  persons 
who  have  a  scrophulous  appearance, 
and  usually  preceded  by,  or  continued 
with,  other  scrophulous  symptoms. 

In  this  disease  of  the  joints,  the  can- 
cellous structure  of  the  bones  is  the  part 
primarily  aflected;  in  consequence  of 
which,  ulceration  takes  place  in  the  carti- 
lages covering  their  articulating  surfaces. 
The  cartilages  being  ulcerated,  the  subse- 
quent progress  of  the  disease  is  in  many 
respects  the  same,  as  where  this  ulceration 
takes  place  in  the  first  instance. 


(      198      ) 

CASE  XLI. 

Thomas  Scales,  aged  18,  liavinga  scro- 
phuloiis  appearance,  was  admitted  into 
St.  George's  Hospital  on  the  18th  of  Oc- 
toher,  1815. 

He  complained  of  pain,  which  he  re- 
ferred to  the  inside  of  one  foot.  The 
pain  was  constant,  hut  slight,  and  not  suf- 
ficient to  prevent  his  walking  as  usual. 
There  was  very  little,  if  an} ,  tumefaction, 
and  the  parts  were  not  tender  to  the 
touch.  He  was  also  in  a  general  ill 
state  of  health:  there  were  symptoms  of 
derangement  of  the  functions  of  the  liver, 
and  the  urine  was  turbid  and  deposited  a 
quantity  of  sediment,  which  stained  the 
vessel  that  contained  it  of  a  pink  colour. 
He  was  heavy  and  stupid,  and  scarcely 
able  to  give  any  consistent  account  of 
his  ailments.  There  were  some  small 
ulcerations  at  the  edges  of  his  e^  elids. 

While  he  was  under  a  course  of  reme- 
dies for  these  complaints,  he  was  seized, 


(     212     ) 

iu  the  beginning  of  February,  1816,  with 
a  fever,  of  which  he  died  on  the  first  of 
March. 

On  dissection,  the  foot,  which  had  been 
the  seat  of  the  pain,  was  particularly  ex-^ 
amined.  Tiie  bones  of  the  tarsus,  and 
metatarsus,  w  ere  found  to  contain  an  un- 
usually small  quantity  of  earthy  matter, 
so  that  they  were  preternaturally  soft, 
and  admitted  of  being  cut  in  any  di- 
rection with  a  scalpel,  without  turning  its 
edge.  The  cut  surfaces  of  these  bones  v.  ere 
of  a  deep  red  colour,  in  consequence  of 
increased  vascularity;  and  vessels  injected 
with  their  own  blood  could  be  distinctly 
traced  extending  from  the  bones  into  the 
cartilages  covering  them,  and  renderhig 
the  latter,  in  a  few  spots,  of  a  red  colour. 
The  cartilage  covering  the  internal  cunei- 
form bone,  where  it  forms  the  joint  w  ith  j 
the  metatarsal  bone  of  the  great  toe,  was 
ulcerated  to  a  small  extent.  The  ulcer- 
ation had  begun  on  that  side  of  the  car- 
tilage which  was  connected  to  the  bone; 
the  surface  towards  the  joint  remaining 


(     218     ) 

entire.  The  bones  of  the  tarsus  were  more 
diseased  than  those  of  the  metatarsus; 
and  those  on  the  inside  of  the  tarsus  were 
affected  in  a  greater  degree  than  those  on 
the  outside.  The  bones  of  the  other  foot 
were  affected  in  the  same  manner,  but  in 
a  much  less  degree.  Some  of  the  other 
bones  y»^ere  examined,  and  were  found 
nearly  in  a  natural  condition. 


CASE  XLLT. 

December  21st,  1814.  In  a  boy  appar- 
ently about  ten  years  of  age,  whose  body 
I  had  the  opportunity  of  examining  after 
death,  I  observed  the  following  appear- 
ances. 

Both  elbows  were  slightly  swollen. 
On  the  fore-part  of  the  right  arm,  imme- 
diately above  the  elbow,  there  was  the 
orifice  of  a  sinus,  which  extended  down- 
wards obliquely  into  the  cancellous  struc- 
ture of  the  bone,  where  it  terminated, 
without  communicating  with  the  cavity 


(      214     ) 

of  the  joint.     The  cancellous  structure, 
of  the  articulating  extremities  of  the  os 
brachii,  radius,  and  ulna,  was  so  soft,  that 
it  might  be  crushed  by  a  very  slight  de- 
gree offeree  when  squeezed  between  the 
fingers:  it  was  of  a  dark  red  colour;  pre- 
ternaturally    yascular,    and   there   was   a 
reddish  fluid,  mixed  with  medulla,  in  the 
cancelli.     The  cartilages  covering  the  ra- 
dius  and  ulna  were  in  a  natural  state; 
that  belonging  to  the  os  brachii  was  ul- 
cerated in  a  few  spots  on  the  surface  to- 
wards the  bone,  w  hile  the  surface  towards 
the  cavity  of  the  joint  was  entire.    There 
were  no  morbid  appearances  of  the  liga- 
ments or  synovial  membrane. 

The  bones  of  the  left  elbow  were  in  a 
similar  state  of  disease;  the  cartilages 
were  entirely  destroyed  by  ulceration; 
and  carious  surfaces  of  bone  were  ex- 
posed. A  small  portion  of  dead  bone 
had  exfoliated  into  the  cavity  of  the 
joint,  where  it  lay,  surrounded  by  matter. 
The  synovial  membrane  and  ligaments 
were    extensively    destroyed,    and  there 


^      215     ) 

were  several  sinuses  communicating  ^vitli 
the  joint  and  opening  externally. 

On  examining'  the  right  knee,  which 
externally  had  not  the  slightest  marks  of 
disease,  and  admitted  of  perfect  motion, 
the  cancellous  structure  of  all  the  bones, 
which  enter  into  its  composition,  was 
found  in  the  same  morbid  condition  with 
the  bones  of  the  elbows,  being  preter- 
naturally  red  and  vascular,  with  a  much 
less  proportion  than  is  usual  of  earthy 
matter,  so  that  they  admitted  of  being 
crushed  by  a  vexy  slight  force.  In  the 
interior  of  the  lower  extremity  of  the  fe- 
mur, between  the  two  condyles,  there  was 
one  part,  where  the  earthy  matter  seemed 
to  have  entirely  disappeared,  and  there 
was  in  consequence  an  irregular  space,  in 
which  there  was  little  else  than  medulla 
and  reddish  fluid  mixed  together;  near 
this  part,  tlic  cartilage  had  only  a  very 
slight  adhesion  to  the  bone,  and  ulceration 
had  begun  on  its  inner  surface. 


(     216      ) 

In  several  other  joints,  which  were 
examined,  there  were  marks  of  the  same 
disease,  but  in  a  less  advanced  stage. 

CASE  XLIII. 

John  King,  twenty-six  years  of  age,  hav- 
ing blue  eyes,  thick  lips,  and  a  florid  com- 
plexion, was  admitted  into  St.  George's 
Hospital,  on  the  1st  of  June,  1811,  on 
account  of  a  complaint  in  his  right  ankle 
and  foot.  I  receiAcd  the  following  ac- 
count of  his  case,  partly  from  himself,  and 
partly  from  a  medical  gentleman,  who 
^as  in  the  habit  of  seeing  him  before  he 
came  into  the  hospital. 

About  the  end  of  May,  1810,  he 
wrenched  his  foot.  The  instep  and  ankle 
became  swollen  and  painful,  but  in  a  few 
days  these  symptoms  subsided.  During 
the  summer  he  experienced  slight  pain 
and  weakness  of  these  parts,  whenever 
he  took  more  than  his  usual  quantity  of 
exercise;   but  in  October  a  slight  tume- 


(     217      ) 

faction  was  observed  on  each  side  of  the 
ankle,  and  the  pain  was  more  severe,  but 
still  not  snfiicicnt  to  prevent  his  going 
about  his  usual  occupations.  About  the 
middle  of  December  the  pain  became 
more  violent,  and  he  was  confined  to  the 
house  for  a  fortnight;  after  this  the  pain 
abated,  so  that  he  was  able  to  go  about 
with  the  assistance  of  a  crutch. 

In  March,  1811,  an  abscess  burst  on 
the  outside  of  the  foot.  The  formation  of 
the  abscess  was  not  attended  with  any 
considerable  degree  of  pain. 

He  formerly  had  been  supposed  to  la- 
bour under  incipient  phthisis  pulmonalis; 
but  from  the  time  of  tlie  disease  havino^ 
begun  in  his  foot,  he  suffered  no  inconve- 
nience from  the  complaint  in  his  lungs. 

At  the  time  of  his  admission  into  the 
hospital,  there  was  a  diffused  cedematous 
swelling  of  the  soft  parts  over  the  whole 
foot  and  ankle.  On  the  outside  there 
were  tlie  orifices  of  three  or  four  sinuses, 


29 


(      218      ) 

which  had  biirst  at  different  periods.  He 
had  very  little  pain,  even  on  motion  or 
pressure.  Soon  after  his  admission,  an- 
other abscess  broke  on  the  inside  of  the 
heel. 

On  the  11th  of  July,  the  leg  was  ampu- 
tated. 

On  examining  the  foot,  the  cells  of  the 
cellular  membrane  were  found  distended 
with  serum  and  coagnlable  lymph. 

All  the  bones  had  undergone  a  morbid 
change,  similar  to  what  was  observed  in 
the  last  case,  except  that  they  were  still 
softer  and  more  vascular. 

The  cartilages  of  the  ankle  were  com- 
pletely destroyed  by  ulceration,  and  the 
exposed  surfaces  of  bone  were  in  a  state 
of  caries.  The  cartilages  of  the  tarsus 
were  entire,  but,  in  some  places,  of  a  red 
colour,  and  this  was  found  to  arise  from 
vessels  loaded  with  red  blood,  extending 
into  them  from  the  bone.  The  ligaments 
and  synovial  membranes  of  the  tarsal 
joints  were  in  a  natural  state,  as  were  alsc? 


(     219     ) 

those  of  the  ankle,  except  Avhere  they  had 
heeii  destroyed  hy  the  abscesses. 

CASE  XLIV. 

This  patient  was  a  soldier  in  the  Cold- 
stream Guards.  I  once  had  an  opportu- 
nity of  seeing  him  before  amputation  was 
performed,  and  through  the  kindness  of 
the  medical  officers  of  the  regiment,  I 
was  favoured  with  the  previous  history  of 
the  coniplaint,  and  with  the  opportunity 
of  examining  the  amputated  joint. 

William  Miles,  twenty  years  of  age,  of 
a  delicate  complexion,  jyith  red  Iiair  and 
dilated  pupils,  was  attacked  with  a  slight 
pain  and  swelling  of  the  left  knee,  about 
the  middle  of  January,  1808.  On  keep- 
ing quiet  for  a  few  days  the  swelling 
subsided;  but  it  returned  about  the  end 
of  March,  though  still  attended  with  very 
little  pain. 

He  was  received  into  the  hospital  of 
the  battalion    at   Chatham,  and   on   the 


(      220      ) 

Otli  of  June  following,  lie  was  sent  Lo  Uio 
regimental  hospital  in  London. 

At  this  time,  the  diseased  knee  measured 
in  circumference  three  inches  more  than 
the  other.  -Fluid  was  felt  external  to  the 
joint,  and  in  the  cavity  of  the  joint  itself. 
The  leg  was  kept  extended,  and  all  at- 
tempts to  hend  it  gave  considerable  pain; 
but  otherwise,  the  pain  which  he  endured 
was  trifling,  amounting  only  to  a  slight 
degree  of  uneasiness,  deep-seated  in  the 
Joint.  On  the  8th  of  July,  an  abscess 
burst  near  the  inner  edge  of  the  patella, 
and  discharsced  about  eisjjht  ounces  of  thin 
pus.  On  the  27th  of  July,  the  limb  was 
amputated. 

On  examining  the  knee,  the  articulating 
extremities  of  the  tibia  and  fibula  were 
found  so  soft,  that  they  w  ere  readily  cut 
by  a  common  knife:  they  contained  mucli 
less  earthy  matter  tlian  is  usual,  and 
their  cancelli  w^erc  filled  by  a  yellow 
cheesy  substance. 

The  cartilage  covering  the  head  of  the 


(      221      ) 

tibia,  was  destroyed  by  ulceration  in  a 
a  few  spots  at  the  margin.  Tliat  of  the 
femur,  was  eroded  for  a  very  small  extent 
behind  the  crucial  ligaments.  The  pa- 
tella, and  the  cartilage  covering  it,  were 
in  a  natural  state.  Coagulable  lymph, 
having  a  gelatinous  appearance,  had  been 
effused  into  the  cellular  texture,  on 
the  outside  of  the  synovial  membrane. 
Pns  was  found  external  to  the  joint,  and 
in  the  joint  itself. 

CASE  XXXYII. 

Charles  Miller,  tv.enty  years  of  age,  hav- 
ing blue  eyes,  light  hair,  and  a  fair  com- 
jdexion,  was  admitted  into  St.  George's 
Hospital,  in  April,  1808,  on  account  of  a 
disease  of  one  foot. 

The  whole  foot  was  swollen  and  oede- 
niatous,  with  two  fistulous  sinuses,  one 
on  the  inside  and  the  other  on  the  out- 
side, through  which  a  small  quantity  of 
scrophulous  matter  was  discharged.      V 


(     222     ) 

probe  having  been  introduced  into  either 
of  these  sinuses,  some  exposed  pieces  of 
bone  might  be  distinguished. 

On  the  16th  of  May,  the  limh  was  am- 
putated below  the  knee.. 

On  examining  the  amputated  foot,  the 
muscles  were  found  pale  and  wasted  from 
want  of  use,  and  the  cellular  membrane 
was  distended  with  coagulable  lymph. 

The  extremities  of  the  tibia  and  fibula, 
all  the  bones  of  the  tarsus,  and  extrcr 
mities  of  the  bones  of  the  metatarsus,  con- 
tained much  less  earthy  matter  than  is 
usual.  They  were  so  soft,  that  they  might 
be  cut  with  a  scalpel  without  the  edge  of  it 
being  turned.  They  were  preternaturally 
red  and  vascular,  and  a  yellow  cheesy  sub- 
stance was  deposited  in  the  cancelli.  The 
cartilage  at  the  base  of  the  fifth  -jietatarsal 
bone  was  destroyed  by  ulceration.  Those 
at  the  bases  of  the  three  middle  metatar- 
sal bones  were  also  destroyed,  aud  the 
exposed  surfaces  of  bone  were  undergo- 


(      223     ) 

ing  the  process  of  exfoliation.  The  carti- 
lages of  all  the  other  bones  were  in  a  natu- 
ral state.  Pus  and  coagulafjle  lymph  had 
been  effused  in  the  neighbourhood  of  the 
dead  and  carious  bones,  and  the  sinuses 
communicated  with  them.  The  synovial 
membranes  and  ligaments  were  in  a 
natural  state,  except  where  destroyed  by 
the  abscesses. 


CASE  XL VI. 

James  Miller,  twenty-one  ^ears  of  age, 
was  admitted  into  St.  George's  Hospital 
on  the  21st  of  May,  1817,  on  account  of 
inflammation  of  the  iris  of  one  eye,  and 
Some  eruptions,  which  had  followed  a  sore 
on  the  prepuce:  and  for  these  complaints 
he  was  put  through  a  course  of  mercury. 

About  the  end  of  July,  soon  after  the 
ftiercurial  course  had  terminated,  he  com- 
plained of  a  slight  degree  of  pain  of  the 
left  ankle.  A  swelling  took  place,  and 
an  abscess  formed  on  the  outside  of  the 


(      224     ) 

ankle,  whick  was  opened  on  the  26tli  of 
September.  Another  abscess  afterwards 
formed,  and  was  opened  on  the  inside. 
It  was  observed,  that  there  was  pain  while 
the  abscesses  were  coming  forward,  but 
little  or  no  pain  after  they  were  opened. 
The  abscesses  continued  open,  and  dis- 
charging matter,  but  the  quantity  of  the 
matter  gradually  diminished. 

About  the  beginning  of  October,  he 
became  affected  with  cough,  and  it  soon 
became  evident  that  he  laboured  under 
tubercles  of  tbe  lungs. 

In  the  beginning  of  December,  he 
complained,  for  the  first  time,  of  pain  of 
the  left  elbow;  and  on  examination,  it 
Avas  found  that  an  abscess  had  already 
presented  itself  underneath  the  skin. 
This  abscess  burst  in  the  beginning  of 
January,  1818,  and  he  scarcely  complained 
of  any  pain  in  the  elbow  afterwards. 

The  disease  in  the  lungs  continued  to 
make  progress,  lie  expectorated  purulent 
matter,  and  died  in  March  following. 


(     225     ) 

On  dissection,  the  lungs  were  found 
extensively  tuberculated,  and  containing 
numerous   abscesses.     The   bones    com- 
posing the  left  ankle,  were  preternaturally 
vascular  and  soft,  so  that  they  might  be 
cut  with  a  scalpel,  and  in  some  parts  a 
small  quantity  of  yellow  cheesy  substance 
was  found  in  the  cancelJi.     The  abscess 
on  the  outside  of  the  ankle  seemed  to  have 
originated  in  the  lower  extremity  of  the 
fibula,    and   there    was    a   cavity    (large 
enough  to  receive  the  end  of  the  little 
finger),  in  that  boncj  made  by  the  process 
of  ulceration,  and  forming  the  bottom  of 
the   abscess.     Both    abscesses    however 
communicated  with  the  joint  itsdif.     The 
cartilages   of  the  ankle  were  nearly  de- 
stroyed;   and   the    tibia    and    astragalus 
were  united,  partly  by  coagulable  lymph, 
and    partly  by    bony    anchylosis.     The 
abscess  in  the  outside  of  the  left  elbow, 
was  found  communicating  with  that  joint 
by  a  large  opening.     The  bones   were  in 
the   same   morbid  condition  as  those  of 
.  30 


(     226     ) 

the  ankle;  the  cartilages  were  entirely 
destroyed  hy  ulceration. 

The  patient  had  never  comjdained  of 
the  right  elbow;  but  after  death,  a  small 
abscess  was  discovered  on  the  inside, 
which  however  did  not  communicate  with 
the  cavity  of  the  joint,  but  appeared  to 
have  originated  in  the  substance  of  the 
bone,  and  to  have  made  its  way  through 
the  periosteum. 

The  cant^ellous  structure  of  the  articu- 
lating extremities  of  the  bones,  which 
composed  the  joints  of  the  knees,  wrists, 
and  the  right  ankle,  were  preter naturally 
soft  and  vascular;  but  there  were  no 
abscesses  connected  with  them,  and  the 
cartilages  were  entire.  The  bones  of 
the  hip  and  shoulder  were  in  a  natural 
state. 

There  was  an  enlarged  absorbent  gland 
in  the  groin,  converted  into  a  cheesy 
substance. 


(     227      ) 

The  preceding  cases  sufficiently  illus- 
trate the  nature  and  progress  of  this  dis- 
ease. The  morhid  affection  appears  to 
have  its  origin  in  the  hones,  which  become 
preternaturally  vascular,  and  containing  a 
less  than  usual  quanity  of  earthy  matter; 
while,  at  first,  a  transparent  fluid,  and 
afterwards  a  yellow  cheesy  substance  is 
deposited  in  their  cancelli. 

From  the  diseased  boncy^  vessels  carry- 
ing red  blood  extend  into  the  cartilage, 
which  afterwards  ulcerates  in  spots,  the 
ulceration  beginning  on  that  surface,  which 
is  connected  to  the  bone.  The  ulceration 
of  the  cartilage  often  proceeds  very  slowly. 
I  have  known  a  knee  amputated  on  ac- 
count of  this  disease,  in  Avhich  the  carti- 
lage was  absorbed,  for  not  move  than  the 
extent  of  a  sixpence.  Occasionally  a 
portion  of  the  carious  bone  dies  and 
exfoliates. 

As  the  caries  of  the  bones  advances, 
pus  is  collected  in  the  joint.  At  last  the 
abscess  bursts  externally,  having;  formed 


^   (^      228     ) 

numerous  and  circuitous  sinuses.  Inllam- 
matioii  takes  place  iu  the  cellular  mem- 
brane external  to  the  joint.  Serum,  and 
afterwards  coagulahie  Ijmph  is  efiused, 
and  hence  arises  a  puflj  and  elastic 
swelling  in  the  early,  and  an  cedeniatous 
swelling  in  the  advanced  stage  of  the 
disease. 

The  scropliulous  aiTection  attacks  only 
those  bones,  or  portions  of  bones,  which 
have  a  spongy  texture,  as  the  extremities 
of  the  cylindrical  bones,  and  the  bones  of 
the  carpus  and  tarsus:  and  hence  the 
joints  become  affected  from  their  conti- 
guity to  the  parts,  which  are  the  original 
seat  of  the  disease.  I  have  never  met 
with  an  instance  of  the  alteration  of 
structure,  which  has  been  just  described, 
in  the  cranium,  nor  in  the  middle  of  the 
cylindrical  bones.* 


*  It  should  be  observed,  that  in  some  other  cases, 
besides  those  of  scrophulous  affection,  the  bones  are 
found  to  be  more  or  less  altered  from  their  natural 


(     229      ) 

Sect.  II. 

On  the  Symptoms  of  this  Disease. 

The  scropliiiloiis  affection  of  the  joints 
occurs  frequently  in  cliiklren:  it  is  rare 
after  thirty  years  of  age.  Examples  of  it 
occur  in  almost  every  joint  of  the  body, 
but  the  hip  and  shoulder  appear  on  the 

texture.  When  a  bone  is  extensively  carious,  it  seems 
as  if  the  absorption  of  the  earthy  part  sometimes  takes 
place  more  rapidly  than  that  of  the  animal  matter, 
and  hence  it  becomes  preternaturally  soft  in  the 
neighbourhood  of  the  carious  surface,  at  the  same 
time  that  It  assumes  a  dark  colour,  and  has  a  fcetid 
smell,  from  the  lodgment  of  putrid  matter  in  the  can- 
celli.  Occasionally  a  bone  loses  some  of  its  natural 
hardness,  in  consequence  (as  it  would  appear)  of  it 
having  been  for  a  long  time  inflamed.  This  hap- 
pened in  two  cases,  which  came  under  my  observation, 
where  the  cranium  had  been  in  a  state  of  slow  inflam- 
mation, induced  in  one  case  by  the  use  of  mercury, 
and  in  the  other  by  a  mechanical  injury.  But  here 
the  softened  condition  of  the  bones  does  not  exist  in 
the  same  degree,  as  in  the  scrophulous  disease,  which 
has  been  described  above,  nor  is  there  the  same  red 
appearance  of  the  cancellous  structure,  nor  the  same 
deposition  of  yellow  cheesy  substance. 


(      2;:J0      ) 

Avliole  to  be  less  liable  to  it  than  any  of  the 
other  articulations.* 

As  it  depends  on  a  certain  morbid  con- 
dition of  the  general  system,  it  is  not 
surprising  that  we  should  sometimes  find 
it  affecting  several  joints  at  the  same 
time;  nor,  that  it  should  shew  itself  in 
different  joints  in  succession;  attacking 
a  second  joint  after  it  has  been  cured  in 
the  first,  or  after  the  first  has  been  re- 
moved by  amputation.  It  is  seldom  met 
with,  except  in  persons  who  have  the 
marks  of  what  is  called  a  scrophulous 
diathesis:  and  in  many  cases  it  is  either 
preceded,  attended,  or  followed,  by  some 
other   scrophulous    symptoms;    such   as 


*  Perhaps  this  arises  from  the  circumstance  of  the 
hip  and  shoulder  being  less  exposed  to  the  influence 
of  the  external  cold,  which  in  most  instances  pro- 
motes the  developement  of  scrophulous  diseases.  So 
Are  find,  the  scrophulous  enlargement  of  the  lympha- 
tic glands,  to  occur  more  frequently  in  the  neck'  than 
in  the  groin  or  axilla,  which  are  generally  defended 
by  a  warmer  clothing. 


(     231      ) 

tBniargement  of  the  scropliulous  glands 
of  the  neck  and  mesentary;  or  tubercles 
of  the  kings.  I  liave  often  been  led  to 
believe,  that  the  occurrence  of  this  dis- 
ease in  the  joint,  has  suspended  the  pro- 
gress of  some  other,  and  perhaps  more 
serious  disease  elsewhere. 

The  scrophulous  disease  is  more  likely 
to  be  confounded  with  that,  which  formed 
tile  subject  of  the  last  chapter,  than  with 
any  other.  There  is  in  many  respects  a 
correspondence  in  their  symptoms.  There 
are  how^ever  certain  points  of  difference, 
and  I  believe  that  this  difference  will  be 
found  sufficient  to  enable  the  practitioner, 
w  ho  is  careful  and  minute  in  his  observa- 
tions, to  make  a  correct  diagnosis;  at  least 
in  those  cases,  in  which  the  local  disease 
is  not  so  far  advanced,  and  in  which  it 
has  not  so  much  affected  the  general  con- 
stitution, as  to  make  the  diagnosis  of  no 
importance. 

While  the  disease  is  going  on  in  the 
soancellous  structure  of  the  bones,  before 


(      232      ) 

it  has  extended  to  the  other  textures,  and 
while  there  is  still  no  evident  swelling, 
the  patient  experiences  some  degree  of 
pain,  Avliich  however  is  never  so  severe  as 
to  occasion  serious  distress,  and  often  is 
so  sliglit,  and  takes  place  so  gradually 
that  it  is  scarcely  noticed. 

After  a  time  (which  may  vary  from  a 
few  weeks  to  several  months)  the  parts 
external  to  the  joint  hegin  to  sympathise 
with  those  within  it;  and  serum  and  co- 
agulable  h  mph  being  effused  into  the  cel- 
lular membrane,  the  joint  appears  swollen. 
The  swelling  is  puffy  and  elastic,  and 
though  usually  more  in  degree  than  it  is, 
at  the  same  period,  in  those  cases,  in 
which  the  ulceration  of  the  cartilages  oc- 
curs as  a  primary  disease,  it  is  not  great- 
er in  appearance,  because  the  muscles  of 
the  limb  are  not  equally  wasted  from 
want  of  exercise.  I  have  observed  that 
in  children,  the  swelling  is  in  the  first  in- 
stance usually  less  diffused,  and  somewhat 
firmer  to  the  touch  than  in  the  adult. 


(      233      ) 

if  a  supicion  of  some  disease  of  tlie 
Joint  has  not  existed  previously,  it  is  al- 
^vays  awakened  as  soon  as  the  swelling 
has  taken  place.  Should  the  patient  be 
a  child,  it  not  uncommonly  happens  that 
the  swelling  is  the  first  thing,  which  the 
nurse  or  the  parents  discover.  This  leads 
to  a  more  accurate  enquiry,  and  the  child 
is  observed  to  limp  in  walking,  if  the  dis- 
ease be  in  the  lower  limb,  and  to  com- 
plain of  pain  on  certain  occassions. 

I  have  said,  that  the  swelling  is  puffy 
and  elastic,  and  after  what  has  been  re- 
marked in  the  former  chapters,  it  is 
needless  to  point  out  more  particularly 
the  difference  between  it,  and  the  swelling 
which  takes  place  in  cases  of  inflamed 
synovial  membrane.  The  swelling  in- 
creases, but  not  uniformly^  and  it  is 
greater  after  the  limb  has  been  miich 
exercised,  than  it  is,  when  it  has  been 
allowed  to  remain  for  some  time  in  a 
state  of  quietude. 

As  the  cartilages  continue  to  ulcerate/ 
31 


(     234     ) 

the  puiu  becomes  somewhat,  but  not 
materially  aggravated.  It  is  not  severe, 
until  abscess  has  formed  and  the  parts 
over  the  abscess  have  become  distended 
and  inflamed.  The  skin  under  these 
circumstances  assumes  a  dark  red  or 
purple  colour.  The  abscess  is  slow  in 
its  progress;  when  it  bursts  or  is  opened^ 
it  discharges  a  thin  pus,  with  portions  of 
curdly  substance  floating  in  it.  After- 
wards  the  discharge  becomes  smaller  in 
quantity,  and  thicker  in  consistence,  and 
at  last  it  nearly  resembles  the  cheesy 
matter,  which  is  found  in  scrophulous 
absorbent  glands. 

In  most  instances  several  abscesses 
take  place  in  succesion,  but  at  various 
intervals;  some  of  which  heal,  while 
others  remain  open  in  the  form  of  fis- 
tulous sinuses,  at  the  bottom  of  which 
carious  bone  may  be  distinguished  by 
means  of  a  probe. 

The  disease  not  unfrequently  remains 
in  this  state  for  several  months,  or  even 


(     235     ) 

for  a  mucli  loger  period,  without  tlie  con- 
stitution being  materially  disturbed.  In 
the  less  fortunate  cases,  the  patient  at  last 
becomes  affected  with  a  hectic  fever,  un- 
der which  he  gradually  sinks,  unless  the 
cause  of  it  be  removed  by  amputation. 
At  other  times,  a  curative  process  begins; 
the  sinuses  close;  the  cedema  subsides; 
and  the  patient  ultimately  recovers,  either 
with  or  without  an  anchylosis;  accord- 
ingly as  more  or  less  destruction  of  the 
articulating  surfaces  has  taken  place.  But 
the  cure  is  always  tedious,  unless  the 
disease  has  been  arrested  at  a  very  early 
period.  It  is  not  uncommon  to  see  a 
patient  with  a  scrophulous  joint,  in  a 
state  of  imperfect  anchylosis,  with  a  single 
sinus  remaining  open,  and  waiting  for 
many  years,  before  even  such  a  cure  as 
anchylosis  affords,  can  be  said  to  be  com- 
pleted. The  chance  of  ultimate  recovery 
is  not  the  same  in  every  articulation;  and 
I  have  observed,  that  it  is  much  less, 
where  the  disease  attacks  the  complicated 


(    23b    ; 

joints  of  tlie  foot  and  liund,  than  when  u 
is  situated  in  those,  Avliicli,  tliougL  of  a 
larger  size,  are  of  a  more  simple  struc- 
ture. 

The  principal  difference  wliich  is  to  he 
observed,  hetweeij  tlie  symptoms,  which 
have  been  just  described,  and  those,  which 
are  met  with,  where  ulceration  of  the  car- 
tilages occurs  as  a  primary  affection,  is  in 
the  degree  of  pain,  which  the  patient  en- 
dures, and  which  is  much  less  in  the 
cases  of  the  former  than  in  those  of  the 
latter  descriptioi]. 

It  may  indeed  be  a  matter  of  surprise, 
that  in  cases  of  this  scrophulous  affection, 
the  sufferings  of  the  patient  should  be  so 
little  as  they  are  found  to  be,  in  propor- 
tion to  the  quantity  of  local  mischief. 
For  the  most  part,  the  pain,  which  he  ex- 
periences, is  not  a  subject  of  serious  com- 
plaint, except  at  the  time  when  an  ab- 
scess is  just  presenting  itself  underneath 
the  skin,  and  then  it  is  immediately  re- 
Jieved  by  the  abscess  bursting.     There  is 


(      237      ) 

4iever  that  severe  pain,Avhich  exhausts  the 
powers  and  the  spirits  of  the  patient,  in 
cases  of  ulceration  of  the  cartihi<^'e,  except 
in  a  very  few  instances,  and  in  the  most 
advanced  stage  of  the  disease,  when  a  por- 
tion of  the  ulcerated  bone  has  died,  and 
having  exfoliated  so  as  to  lie  loose  in  the 
cavity  of  the  joint,  irritates  the  parts,  with 
which  it  is  in  contact,  and  thus  becomes 
a  source  of  constant  torment. 

There  are  other  circumstances,  besides 
the  less  degree  of  pain,  which  although 
not  in  themselves  sufficient,  it  is  useful  to 
take  into  the  account  in  forming  our 
diagnosis;  such  as  the  general  aspect  and 
constitution  of  the  patient,  and  his  having 
manifested  a  disposition  toother  scrophu- 
lous  symptoms;  the  very  tedious  progress 
of  the  disease;  and  the  circumstance  of 
the  suppui'ation  not  behigin  general  con- 
fined to  a  single  collection  of  matter;  but 
producing  a  succession  of  abscesses. 

Perhaps  it  is  on  the  whole  more  diffi- 
cult to  distinguish  this  disease  in  the  hip, 


(      238      ) 

than  in  any  other  joint;  since  the  ap- 
pearance of  the  nates  as  well  as  the 
position,  and  the  alteration  in  the  length 
of  the  limb,  give  it  in  great  measure  the 
same  character  with  the  disease,  which 
formed  the  subject  of  the  last  chapter.  Yet 
even  here,  attention  to  the  circumstances 
which  have  been  enumerated,  will  usually 
enable  us  to  distinguish  the  real  nature 
of  the  case.  A  girl  laboured  under  an 
affection  of  the  hip-joint,  in  which  the 
nates  were  flattened,  the  limb  had  become 
shortened,  and  an  abscess  had  broken  on 
the  outside  of  the  thigh;  but  it  was  ob- 
served that  she  had  suffered  comparatively 
little  distress,  and  that  she  had  complained 
of  very  much  less  pain,  than  is  usual  with 
the  same  combination  of  symptoms. 
Under  these  circumstances  she  died,  and 
when  I  was  about  to  examine  the  body,  I 
observed  to  those  who  were  present,  that 
there  was  little  doubt,  but  that  the  origin 
of  the  disease  would  be  found  to  have 
been,   not  in    the   cartilaginous    surface, 


(     239     ) 

but  in  the  cancellous  structure  ot*  tlie 
bone^  The  appearances  which  were  ob- 
served verified  this  remark.  The  car- 
tilages were  ulcerated,  and  the  bones 
themselves  destroyed  to  some  extent. 
The  latter  were  soft,  so  that  they  might 
he  cut  with  a  scapel,  without  turning 
its  edge;  and  on  dividing  the  articulat- 
ing extremity  of  the  femnr  longitudinally, 
a  considerable  collection  of  thick  pus 
was  found  in  the  neck  of  that  bone, 
below  the  head,  which  either  had  noL 
escaped  at  all,  or  had  escaped  in  very 
small  quantity,  hy  oozing  through  the 
cancelli,  which  were  interposed  between 
it^  and  the  cavity  of  the  hip-joint. 


Sect.  III. 

On  the  Treatment. 

In    atempting   the  cure  of  the    scro- 
phulous  disease  of  the  joints,  it  is  neces« 


(    2J4o    ; 

'  sary  to  bear  in  mind,  tliat  it  depends  on 
a  certain  morbid  condition  of  tbe  general 
system.  It  seems  reasonable  to  expect, 
tbat  when  the  local  affection  has  once 
begun  to  exist,  local  remedies  may  be  of 
service  in  checking  its  progress;  but  that 
with  a  view  to  the  ultimate  result,  such 
remedies  as  operate  on  the  constitution 
of  the  patient,  may  be  of  as  much,  if 
hot  of  more  importance,  than  any  local 
treatment. 

I  cannot  say,  that  the  abstraction  of 
blood  froni  the  neighbourhood  of  the 
diseased  joint  is  never  useful,  but  it  cer- 
tainly is  not  necessary  in  ordinary  cases. 
The  state  of  the  cancellous  structure  of 
the  bones  approaches  to  that  of  inflam- 
mation, and  the  cartilages  have  the  ap- 
pearance of  being  inflamed,  before  they 
begin  to  ulcerate;  but  the  inflammation 
is  of  a  specific  kind,  and  like  scrophulous 
inflammation  in  other  parts,  is  not  likely 
to  be  relieved   by  the  loss  of  blood,  ift 


(      211      ) 

the  same  degree  as  common  inflamma- 
tion. I  have  seldom  known  any  benefit 
to  be  derived  from  the  use  of  blisters  oi* 
stimulating  liniments:  nor  in  the  cases,  in 
which  I  have  tried  them,  have  I  observed 
caustic  issues  to  be  productive  of  those 
good  effects,  which  are  so  distinct  in  ano' 
ther  variety  of  disease. 

Cold  evaporating  lotions  seem  to  check, 
in  some  degree,  the  extension  of  the  dis- 
ease from  the  hones  to  the  other  textures, 
and  to  retard  the  occurrence  of  suppura- 
tion, and  they  may  be  employed  with  ad- 
vantage, in  the  early  stage  of  the  com- 
plaint- 

But  neither  at  this,  nor  at  any  other 
period,  is  any  thing  of  so  much  import- 
ance, as  that  the  joint  should  be  kept  in  a 
state  of  quietude.  All  motion,  and  pres- 
sure of  the  articulating  surfaces  against 
each  other  is  likely  to  promote  the  ulcer- 
ation of  the  cartilages,  and  hasten  the 
formation  of  abscess.  We  cannot  sup- 
pose that  rest  will  contribute  to  the 
32 


(     242     ) 

amendment  of  the  scrophuloiis  state  of 
the  bones  themselves;  but  it  may  da 
much  towards  preventing  the  disease 
from  aftecting  the  other  parts.  I  do  not 
mean  to  assert,  that  in  every  case,  the 
patient  should  be  kept  in  a  state  of  ab- 
solute rest  for  a  long  period,  but  cer- 
tainly all  motion  and  exercise  of  the 
limb  should  be  avoided,  as  much  as  pos- 
sible, consistently  with  due  attention  to 
the  state  of  the  patient's  health,  and  the 
impi'ovement  of  his  constitution.  If  the 
disease  be  in  the  lower  extremity,  he 
should  never  rest  the  weight  of  the  body 
on  the  foot  belonging  to  it;  he  should 
never  walk,  except  with  the  assistance  of 
a  ei'Utch;  and  he  should,  if  possible,  be 
exposed  to  the  fresh  air,  by  means  of 
some  kind  of  open  carriage,  rather  than 
in  any  other  way.  If  it  be  in  the  upper 
extremity,  the  hand  and  fore-arm  should 
be  supported  by  means  of  a  sling.  In 
many  cases,  it  will  be  useful  to  keep  the 
diseased  joint  steady  by  means  of  a  light 
paste-boait  splint  and  a  bandage. 


(      243      ) 

During  the  formation  of  abscesses, 
fomentations  and  poultices  may  be  em- 
ployed, with  a  view  to  hasten  their  pro- 
gress, and  relieve  pain;  and  they  may  be 
continued  for  some  time  after  the  abscess 
has  burst;  or  simple  dressings  maybe  ap- 
plied accorduig  to  circumstances. 

When,  after  several  abscesses  have  taken 
place,  the  disposition  to  suppuration  ap- 
pears at  length  to  have  ceased,  and  the 
swollen  joint  has  become  diminished  in 
size,  it  may  be  expected  that  a  curative 
process  by  means  of  tyichylosis,  is  about 
to  commence.  At  this  period,  pressure 
by  means  of  stripes  of  linen,  spread  with 
soap  cerate,  or  some  other  moderately 
adhesive  plaister,  and  applied  in  a  cir- 
cular manner  round  the  limb,  will  be 
productive  of  benefit.  This  will  promote 
the  healing  of  the  sinuses,  and  by  more 
completely  preventing  the  motion  of  the 
joint,  will  lessen  the  chance  of  fresh  sup- 
puration, and  favour  the  union  of  the 
ulcerated  bony  surfaces. 


(^     244     ) 

If  a  portion  of  the  bone  has  lost  its 
living  principle,  and  has  exfoliated  into 
the  cavity  of  the  joint,  the  chance  of 
ultimate  recovery  is  very  much  dimi- 
nished. For  the  most  part,  the  dead 
bone  is  so  entangled  in  the  living  parts, 
that  it  is  incapable  of  separation  by  a 
natural  process,  and  every  attempt  to 
remove  it  by  artificial  means  will  occa- 
sion a  fresh  attack  of  inflammation  and 
abscess.  It  is  to  be  observed,  however, 
that  bone,  which  is  found  exposed  at  the 
bottom  of  a  sinus,  is  not  necessarily 
doomed  to  exfoliate.  It  may  be  simply 
ulcerated,  and  may  possibly  granulate,  and 
recover;  and  tlie  surgeon,  therefore,  is  not 
warranted  in  giving  a  prognosis,  which  is 
decidedly  unfa voui  able,  merely  because  he 
discovers  apiece  of  exposed  bone,  when  he 
makes  an  examination  with  a  probe. 

With  respect  to  the  constitutional  treat- 
ment;— it  is  to  be  supposed,  that  the  air 
of  a  crowded  city,  must  be  more  or  less 
unfavourable;   and  that   a   residence    on 


(     245     ) 

the  sea-coast  is  likely  to  be  more  be- 
neficial tlian  a  residence  in  tlie  country 
elsewhere.  The  patient  should  live  on  a 
nourishing  but  plain  diet;  he  should 
be  in  the  open  air  in  summer,  as 
niuch  as  he  can  be,  without  exercising 
the  joint.  His  mode  of  life  should,  in 
all  respects,  be  regular  and  uniform. 

It  is  more  difficult  to  appreciate  the 
value  of  medicines  in  a  disease,  which  is 
so  completely  chronic,  than  in  acute  dis- 
eases; but  of  those,  which  I  have  tried, 
it  lias  appeared  to  me,  that  preparations 
of  iron  are  much  more  useful  than  any 
others.  They  must,  however,  be  con- 
tinued for  a  considerable  length  of  time, 
aud  in  order  that  this  may  be  effected,  it 
is  generally  necessary  that  diiferent  pre- 
parations should  be  given  in  succession, 
a  change  being  made,  wlienever  the  pa- 
tient begins  to  loathe  that,  which  he  is 
already  taking.  Of  course  the  steel  me- 
dicine should  be  suspended  if  it  excites 
any  febrile  action  in  the   system,  or  if  a 


(      246      ) 

febrile  action  be  excited  in  consequence 
of  the  formation  of  abscess.  Under  these 
circumstances  the  mineral  acids  may  be 
substituted  for  it  with  advantage.  In 
children,  it  will  be  generally  found  use- 
ful to  combine  the  plan  of  treatment, 
which  has  been  just  described,  with  the 
occasional  exhibition  of  mercurial  pur- 
gatives* 

When  the  organization  of  the  joint  is 
completely  destroyed,  and  the  consti- 
tution has  become  aftected,  so  that  the 
patient's  health  is  evidently  failing,  there 
can  be  no  doubt  of  the  necessity  of  the 
local  disease  being  removed  by  ampu- 
tation. But  a  question  concerning  the 
expediency  of  this  operation  will  often 
arise  under  other  circumstances.  The 
patient  has  hitherto  not  suffered  with  re- 
spect to  liis  general  health,  or  has  suffered 
in  a  very  slight  degree;  the  condition  of 
the  diseased  joint  is  such  that  ultimate 
recovery  is  very  doubtful;  and  it  is  cer- 
tain that  no  better  cure  is  to  be  expected 


(     247      ) 

than  that  by  means  of  anchylosis;  and 
even  this  cannot  be  looked  for  except 
after  the  lapse  of  a  considerable  length 
of  time.  Is  the  chance  of  the  ultimate 
preseryation  of  an  imperfect  limb  suffi- 
cient to  repay  the  patient  for  all  the 
trouble,  and  pain,  and  anxiety,  which  he 
must  go  through,  in  order  to  attain  this 
object?  Perhaps  it  is  not:  particularly 
with  persons  belonging  to  the  lower 
orders  of  society,  who  have  to  support 
themselves  by  their  bodily  labour.  There 
are  however  some  other  points  to  be 
taken  into  consideration,  before  this 
question  can  be  properly  decided.  A 
girl  was  admitted  into  St.  George's  Hos- 
pital, who  laboured  under  this  disease  in 
the  bones  and  joints  of  the  tarsus.  Her 
foot  was  amputated  by  Mr.  Griffiths.  In 
about  three  weeks  the  stump  was  per- 
fectly healedj  but  now  she  was  seized 
with  symptoms,  which  indicated  an  af- 
fection of  the  mesenteric  glands,  which 
had  not  shewn  itself  previously,  and  she 


(      248      ) 


died.     On  dissection,  numerous  glands  of 
the  mesentery  were  found  enlarged,  and 
containing  a   cheesy   matter.      Another 
girl,  whose  arm  I  amputated  on  account 
of  a  scrophulous  disease  of  the   elbow, 
became  affected  in  the  same  manner,  im- 
mediately after  the    stump  was  healed. 
She  also   died,  and  similar  appearances 
presented  themselves  on  dissection.     A 
man,   whose   leg  was   amputated  on  ac- 
count  of  a   scrophulous  disease  of  the 
tarsus,  in  a  short  time  after  the  operation, 
began   to    experience    symptoms,   which 
indicated  the  incipient  state  of  some  pul- 
monic  complaint:    and   soon   afterwards 
the   other   foot  became   affected   in   the 
same  manner  as  the  first.     These  are  a 
few  of  many  cases,  which  might  be  ad- 
duced,  as    leading    to    this    conclusion, 
that  the  occurrence  of  this   scrophulous 
disease  in  a  particular  joint  may  be  the 
means  of  preventing  the  scrophulous  dis- 
position from  shewing  itself  in  some  other 
organ,  and   that  if  the  affected  joint  be 


(      249      ) 

removed  by   an  operation  there  is  more 
danger   of    disease    breakini^    out    else- 
where,   than    if    the    operation    had   not 
been   resorted   to.      I   do   not  say   that 
these  considerations  are  sufficient  to  war- 
rant the   surgeon  in  forbidding  an  oper- 
ation altogether,  in   all  cases,  where  it  is 
not  actually  and  indisputably  necessary  to 
save  the   patient's  life;  but  they  are  cer- 
tainly sufficient  to  make  him  cautious  not 
to  recommend  and   urge  it  too  strongly. 
They  shew  the  prudence  of  delay  in  cer- 
tain cases.     Perhaps  after   the   lapse   of 
one,  or  two,  or  more  years,  by  means  of 
proper    medicines,   and   a  judicious    at- 
tention to  diet,  and  mode  of  life,  and  still 
more  in  consequence  of  that  change,  which 
the  mere  lapse  of  time  may  produce  in 
the  constitution  of  a  young  person,  the 
patient's  general  health  may  be  so  far  im- 
proved, that  the  diseased  joint  may  be  re- 
moved, without   the  risk   of  subsequent 
mischief,  which  would  have  been  incurred 
at  a  former  period. 

33 


(     250     ) 

Sect.1V. 
Cases  of  this  Disease. 

Several  of  the  cases  related  in  the 
first  section,  will  serve  to  explain  the  prin- 
cipal circumstances  of  this  scrophulous 
affection  of  the  joints,  in  its  most  aggrava- 
ted form. 

The  following  exhihit  it  in  its  less  ad- 
vanced stages,  where  it  is  still  capable  of 
a  cure.  It  may  be  presumed  that  in  these 
cases,  the  original  disease  was  that  mor- 
bid condition  of  the  cancellous  structure 
of  the  boneSj  which  has  been  just  de- 
scribed, since  the  symptoms  exactly  cor- 
responded to  those,  which  have  occurred 
in  other  cases,  which  have  been  proved  by 
dissection  to  be  of  this  nature. 

CASB  XLYII. 

William  Moulds,  six  years  of  age,  hav- 
ing a  scrophulous  aspect,  was  admitted 


(     251     ) 

into  St.  George's  Hospital,  on  the  23d  of 
February,  1814. 

His  left  knee  was  an  inch  and  a  half 
in  circumference  larger  than  the  other. 
The  swelling  was  puffy  and  elastic;  with- 
out fluctuation,  having  nearly  the  form  of 
the  articulating  extremities  of  the  bones; 
but  filling  up  the  space  on  each  side  of 
the  ligament  of  the  patella.  The  joint 
admitted  of  considerable  motion,  but  not 
of  complete  flexion  and  extension.  He 
complained  of  pain,  which  was  worst  at 
night,  but  never  very  severe.  It  was 
somewhat  aggravated  by  pressure. 

His  parents  attributed  the  complaint 
to  some  trifling  hurt,  which  he  had  met 
with  a  year  ago;  soon  after  which,  a  slight 
degree  of  pain'  and  tumefaction  was  first 
observed,  which  had  continued  ever  since, 
and  had  increased,  particularly  within  the 
last  month. 

On  his  admission,  with  a  view  to  the 
relief  of  the  external  inflammation,  blood 
was  taken  from  the  knee  by  means  of 


(     252     ) 

leeches  and  ciippijig.  A  cold  lotion  wab 
applied;  and  he  was  directed  to  take  3) 
of  the  vinum  ferri,  with  a  few  drops  of 
the  tinctura  ferri  muriatis  three  times  in 
the  day.  On  the  3d  of  March,  the  knee 
was  bound  up  in  stripes  of  linen  spread 
with  soap  cerate,  chiefly  with  a  view^  to 
restram  the  motion  of  the  diseased  joint, 
without  interfering  with  the  patient's  bo- 
dily exercise. 

March  20.  The  swelling  was  somewhat 
diminished;  and  he  did  not  complain  of 
pain. 

April  1 .  He  ^^  as  in  all  respects  better. 
As  the  former  preparations  of  iron  had 
begun  to  disagree  with  him,  they  were 
chan2:ed  for  ten  trains  of  the  carbonate  of 
iron,  three  times  in  the  day. 

April  20.  Scarcely  any  swelling  of  the 
joint  remained:  and  there  was  no  pain  or 
stiffness.     He  quitted  the  hospital 


(      253     ) 

CASE  XLVIII 

A.  B.,  a  handsome  boy,  having  bhie 
eyes,  and  light  hair,  in  the  year  1806  had 
a  scrophuloiis  enlargement  of  some  of  the 
glands  of  his  neck,  which  suppurated  and 
burst. 

In  the  month  of  June,  1810,  being  then 
eight  years  .  of  age,  he  was  observed  to 
limp  in  walking;  but  he  did  not  com- 
plain of  pain,  and  little  notice  was  taken 
of  this  circumstance. 

In  the  beginning  of  December,  1810, 
some  degree  of  tumefaction  was  observed 
of  the  left  instep  and  ankle.  About  the 
end  of  this  month  he  received  a  trifling 
hurt  of  these  parts;  and  now  the  pain  of 
the  ankle,  which  before  had  been  so 
slight,  that  he  scarcely  spoke  of  it,  became 
more  considerable,  and  he  was  unable 
to  walk.  A  gentleman  who  was  consulted 
directed  the  application  of  blisters,  but 
they  were  productive  of  no  relief. 

In  the  middle  of  January,  1811,  when 


(      254      ) 

1  was  first  consulted,  there  was  a  pufiV 
elastic  swelling  on  each  side  of  the  ankle 
and  instep;  there  w^as  scarcely  any  pain 
when  the  joint  was  perfectly  quiet;  but 
on  attempting  to  use  it,  the  pain  was 
more  considerable,  and  it  was  particularly 
aggravated,  when  the  heel  was  pressed 
upwards  against  the  bones  of  the  leg.  In 
other  respects  he  was  in  perfect  health. 

I  directed  him  to  take  the  sulphate  of 
iron  internally,  and  to  avoid  all  exercise  of 
the  joint,  walking  only  on  crutches,  and 
so  as  never  to  place  his  foot  in  contact  with 
the  ground.  Stripes  of  linen  spread  with 
soap  cerate,  were  applied  for  the  purpose 
of  more  effectually  restraining  motion. 

I  did  not  see  him  again  until  the  be- 
ginning of  March,  when  the  pain  and 
swelling  were  found  to  be  somewhat  di- 
minished. As  the  stripes  of  soap  cerate 
did  not  seem  sufficiently  to  answer  the 
intended  purpose,  a  light  pasteboard 
splint  was  applied  on  each  side  of  the  leg 


(     255     ) 

and  foot,   and   secured  by   means   of  a 
bandage. 

April  12th.  The  puffy  swelling  was  evi- 
dently diminished,  and  there  was  no  pain, 
even  when  the  heel  was  pressed  upwards 
against  the  tibia.  The  same  treatment 
was  continued. 

May  26th.  The  swelling  was  further 
diminished;  and,  on  the  29th  of  June,  the 
affected  foot  and  ankle  scarcely  dijffered  in 
appearance  from  the  other.  He  was  free 
from  pain  even  on  motion.  The  splints 
were  left  off,  hut  it  was  directed  that  he 
should  continue  to  wear  the  bandage. 
He  was  allowed  occasionally  to  put  his 
foot  on  the  ground. 

July  20th.  He  continued  well.  He 
went  to  the  sea-side,  with  directions  to 
continue  the  steel  medicine,  and  to  bathe 
in  the  sea  twice  in  the  week. 

CASE  XLIX. 

George  Lavel,  nine  years  of  age, 
and  having  a  scrophulous  appearance,  in 


(      256      ) 

January,  1817,  complained  of  an  aching 
in  his  leh  elbow,  and  in  about  two  or 
three  months  it  was  observed  that  the 
elbow  was  swollen.  In  May,  1817,  he 
became  an  out-patient  of  St  George's 
Hospital.  At  this  time,  the  elbow  was 
swollen,  and  painful,  but  the  pain  arose 
chiefly  from  an  abscess  which  presented 
itself  underneath  the  skin  on  the  inside. 
After  the  abscess  had  burst,  it  was  ob- 
served that  the  swelling,  which  was  in- 
dependent of  it,  was  not  considerable, 
and  that  it  seemed  to  arise  entirely  from 
an  effusion  of  serum  and  coagulablc 
lymph  into  the  cellular  membrane  ex- 
ternal to  the  joint.  From  this  time  he 
suffered  very  little  pain,  until  the  be- 
ginning of  January  1818,  when  another 
abscess  began  to  shew  itself  on  the  out- 
side of  the  elbow.  On  the  28th  of 
Januar}'^  he  was  admitted  as  an  in-patient 
of  the  hospital.  The  joint  now  admitted 
of  very  limited  motion.  Whenever  it  was 
moved,  or  when  the  articulating  surfaces 
were  pressed  against  each  other,  he  com- 


(     257     ) 

plained  of  some  but  not  of  severe  pain. 
He  kept  the  fore-arm  in  the  half-bent 
position,  and  walked  about,  supportinj^ 
the  hand  in  a  sling,  with  very  little 
inconvenience. 

In  the  beginning  of  February,  he  was 
directed  to  take  six  grains  of  carbonate 
of  iron  three  times  in  the  day;  and  a 
purge  of  calomel  and  rhubarb  was  ad- 
ministered occasionally.  The  abscess 
was  opened,  and  a  poultice  was  applied. 

March  1st.  The  joint  was  smaller,  but 
he  was  feverish,  and  suffered  pain  at 
night. 

March  21st.  The  swelling  was  much 
diminished,  the  pain  had  abated;  he  slept 
well  at  night,  and  was  free  from  fever. 

In  the  middle  of  May  there  was  a  re- 
currence of  pain  in  the  joint,  and  another 
abscess  presented  itself  on  the  outside, 
which  was  opened  on  the  19th  of  May. 
After  this  a  fourth  abscess  formed  on  the 
fore-part  of  the  elbow,  and  broke  on  the 
23d  of  June. 

34 


(     258     ) 

July  4th.  There  was  little  or  no  swelling. 
He  was  free  from  pain;  the  abscesses 
continued  open,  discharging  a  very  small 
quantity  of  matter. 

The  poultices  and  fomentations,  which 
had  been  hitherto  employed  during  the 
formation  of  the  abscesses,  were  now  left 
off;  and  some  simple  dressings,  and  a 
bandage,  were  applied  in  their  stead. 
The  swelling  continued  to  subside;  he 
had  no  return  of  pain  or  abscess.  On 
the  4th  of  September,  the  joint  was  not 
larger  than  the  other;  it  admitted  of 
much  more  motion  than  formerly;  there 
was  no  pain;  there  was  still  one  sinus, 
which  was  not  completely  closed,  an4 
which  discharged  a  minute  and  almost 
imperceptible  quantity  of  matter;  all  the 
other  abscesses  were  completely  healed. 


CHAP.  VI. 

©N  CARIES  OF  THE  SPINE, 

Sect.  I.. 

Pathological  Observations,. 

It  is  obvious  from  the  structure  of  the 
vertebral  joints,  that  they  can  be  liable  to 
no  diseases  bearing  any  resemblance  to 
the  affections  of  the  synovial  membrane, 
which  occur  in  other  articulations.  But 
analogy  would  lead  us  to  expect,  what 
experience  demonstrates,  that  those  dis- 
eases, which  commence  in  the  harder 
textures  may  occur  here  as  elsewhere, 
and  that  an  extensive  caries  of  the  spine 
may  have  its  origin,  sometimes  in  an  ul- 
ceration of  the  intervertebral  cartilages, 
and  at  other  times  in  a  morbid  con- 
dition of  the  cancellous  structure  of  the 
bodies  of  the  vertebrae. 


(     260     ) 

In  one  of  tlie  cases,  wliich  have  been 
related  in  a  former  chapter,  where  ulcer- 
ation of  the  articular  cartilages  had  begun 
in  several  other  parts,  tliose  between  the 
bodies  of  some  of  the  dorsal  vertebrfe 
were  found  to  have  been  very  much  al- 
tered from  their  natural  structure.  I 
had  an  opportunity  of  noticing  a  similar 
morbid  condition  of  two  of  the  inter- 
vertebral cartilages  in  a  patient,  who, 
some  time  after  having  recei^  ed  a  blow 
on  the  loins,  was  affected  with  such 
symptoms,  as  induced  Mr.  Keate  to  con- 
sider his  case,  as  one  of  incipient  caries 
of  the  spine,  and  to  treat  it  accordingly 
with  caustic  issues;  and  who,  under  these 
circumstances,  died  of  another  complaint. 
In  various  other  instances,  in  which  the 
patients  had  died  in  the  advanced  stage 
of  caries  of  the  spine,  and  in  which  the 
appearances  were  examined  after  death, 
I  observed  that  the  destruction  of  the 
intervertebral  cartilages  was  much  greater 
than  that  of  the  bones  themselves,  the  lat- 


(     261     ) 

ter  having  retained  their  ordinary  struc- 
ture and  hardness,  and  the  caries  of  them 
heing  either  entirely  confined  to,  or  most 
extensive  on,  those  surfaces,  to  which  the 
cartilage  had  been  connected. 

The  above  circumstances  seem  to  ren- 
der it  probable  that  this  affection  of  the 
spine  frequently  originates  in  the  inter- 
vertebral cartilages.  The  following  cases 
afford  a  more  direct  evidence  in  favour  of 
this  opinion. 

CASE  L. 

Christiana  Clear,  a  girl  eight  years  of 
age,  was  admitted  into  the  Infirmary  of 
the  parish  of  St.  Greorge,  Hanover-square, 
in  the  year  1808,  on  account  of  a  disease 
of  the  spine.  At  this  time,  the  upper 
part  of  the  spine  was  bent  forward,  and 
the  spinous  processes  of  some  of  the 
dorsal  vertebrse  formed  a  preternatural 
projection  at  the  posterior  part;  but  still 
she  was  able  to  walk  without  assistance. 


(      2&2      ) 

Soon  after  her  admissioD,  an  abscess 
presented  itself,  and  burst  in  the  groin; 
and  this  was  followed  by  a  second  ab- 
scess, which  burst  near  the  former. 

The  child  was  now  under  the  necessity 
of  being  confined  entirely  to  her  bed.  The 
abscesses  continued  to  discharge  pus.  She 
became  affected  with  hectic  fever;  never- 
theless more  than  two  years  elapsed  from 
the  time  of  her  having  been  first  admit- 
ted into  the  infirmary',  before  she  died. 

The  body  was  examined  by  Mr.  How- 
ship,  to  whom  I  am  indebted  for  this 
account  of  the  case.  It  was  universally 
anasarcous.  The  abdominal  muscles  were 
so  wasted  that  scarcely  any  vestige  of 
them  was  perceptible.  This  probably 
arose  from  the  circumstance  of  the  child 
having  remained  in  bed  for  so  long  a 
time  previous  to  her  death,  and  having 
scarcely  ever  varied  her  position. 

At  the  posterior  part  of  the  abdomen, 
there  was  a  confused  mass  of  soft  sub- 
stance, which  proved  to  be  the  parietes 


(      263     ) 

ol'an  abscess  communicating   with    the 
orifices  in  the  groin. 

The  bodies  of  the  lowest  dorsal,  and 
three  superior  lumbar  vertebrse  were  found 
at  the  posterior  part  of  the  abscess,  nearly 
consumed  by  caries.  There  were  no  re- 
mains of  the  intervertebral  cartilages  be- 
tween the  tenth  and  eleventh  dorsal,  nor 
between  the  third  and  fourth  lumbar,  ver- 
tebrae. These  intervertebral  spaces  were 
filled  with  pus,  and  the  opposite  surfaces 
of  the  vertebrse  were  carious,  but  only  to 
a  small  extent.  The  central  part  of  the 
intervertebral  cartilage  between  the  ninth 
and  tenth  dorsal  vertebrae  had  been  com- 
pletely absorbed,  and  pus  was  found  in  its 
place.  Externally  to  this,  the  concentric 
layers  of  elastic  cartilage  were  entire, 
though  somewhat  altered  from  their  na- 
tural appearance. 

CASE  LI. 

Mr.  M.,  a  yonng  man,  in  the  suUi- 
mer  of  1816,  became  affected  with  pain 


(      264      ) 

in  liis  back,  and  general  debility,  wliicli 
he  attributed  to  bis  having  lain  on  damp 
ground,  while  in  the  island  of  Ascension, 
in  the  preceding  March.  In  the  begin- 
ning of  September  he  sailed  for  England, 
being  compelled  to  return  home,  on  ac- 
count of  the  state  of  his  health. 

In  February,  1817,  he  arrived  in  Lon- 
don; complaining  of  pain  in  the  back, 
and  numbness  of  the  thighs.  Soon  after- 
wards, on  examining  the  spine  it  was  ob- 
served that  that  part  of  it,  which  is 
formed  by  the  dorsal  vertebrae,  was  in- 
curvated  forward,  and  that  in  addition  to 
this  these  was  an  evident  lateral  incurv- 
ation also.  After  this,  an  abscess  burst 
in  one  groin,  and  continued  open,  dis- 
charging a  large  quantity  of  matter.  The 
lower  extremities  became  imperfectly  pa- 
ralysed; he  lay  constantly  on  one  side, 
with  the  thighs  drawn  forwards,  so  that 
his  knees  nearly  touched  his  chin,  and 
never  varied  from  this  position.  He 
lingered  until  the  lOtli  of  August,  1818, 
when  he  died. 


(      205      ) 

On  inspecting  the  body,  1  lound  an 
abscess,  which  occupied  nearly  the  whole 
of  the  anterior  surface  of  the  spine,  from 
the  upper  part  of  the  posterior  medias- 
tinum as  low  as  the  pelvis,  and  which 
communicated  with  each  groin,  extending 
downwards  in  the  direction  of  the  psoce 
muscles.  In  many  parts,  in  consequence 
of  the  contact  of  the  matter  of  the  abscess, 
tlie  bodies  of  the  vertebrie,  and  even  the 
heads  of  the  ribs,  were  affected  with  a 
superficial    paries. 

There  were  no  remains  of  the  inters 
vertebral  cartilage  between  the  fourth  and 
fifth  dorsal  vertebrae,  and  the  opposite 
surfaces  of  these  two  vertebrae  were  con- 
siumed  by  caries  to  some  extent,  and 
hence  arose  the  curvature  of  the  spine 
forward;  and  they  were  consumed  to  a 
greater  extent  towards  the  left  side,  than 
towards  the  rigbt,  and  hence  arose  the 
Lateral  curvature. 

The  intervertebral  cartilage  between  the 
eleventh  and  twelfth  dorsal  vertebrae  had 
35 


(      2b6     ) 

also  entirely  disappeared,  and  the  oppo- 
site  surfaces   of  these  bones   were  in  a 
state  of  caries;  but  this  had  not  extended 
itself  sufficiently  to  occasion  any  sensible 
loss  of  bony  substance. 

The  intervertebral  cartilages  between 
the  third  and  fourth,  fifth  and  sixth,  se- 
venth and  eighth,  tenth  and  eleventh  dor- 
sal Vertebrse;  and  also  that  between  the 
twelfth  dorsal  and  first  lumbar  vertebra*, 
were  all  found  in  a  perfectly  natural  state 
towards  the  circumference;  but  in  the 
centre,  they  were  of  a  dark  colour;  and 
on  the  surfaces  towards  the  bones  they, 
as  well  as  the  bones  themselves^  were  in 
a  state  of  incipient  ulceration,  but  with- 
out any  appearance  of  pus  having  been 
secreted. 

All  the  other  intervertebral  cartilages 
were,  throughout  their  whole  substance, 
in  a  natural  conditioni  and  the  bones  of 
the  vertebrse  every  where  had  their  na- 
tural texture  and  hardness.  On  laying 
open  the  theca  vertebralis,  the  membranes 


(      267      ) 

of  the  spinal  marrow  were  found  adhering 
together,  behind  the  space  between  the 
fo.urth  and  fifth  dorsal  vertebrae. 


The  above  cases,  and  the  circumstances 
before  mentioned,  seem  to  warrant  the 
conclusion,  that,  in  many  instances,  caries 
of  the  spine  has  its  origin  in  an  ulcer- 
ation of  the  intervertebral  cartilages  be- 
ginning in  their  centre,  and  extending  to 
their  circumference,  and  afterwards  aflect- 
ins;  the  bodies  of  the  contiguous  vertebrae. 


But  there  is  no  doubt,  that  there  are 
other  cases,  in  which  caries  of  the  spine 
has  its  origin  in  the  bones  themselves. 
The  bodies  of  the  yertebrse  are  liable  to 
that  peculiar  disease  of  the  cancellous 
structure,  which  occurs  in  the  articulating 
extremities  of  other  bones,  and  there  in 
no  reason,  why  it  should  not  produce  the 


same  results  here,  as  elsewhere.  The  fol- 
lowing cases,  the  first  of  which  occurred 
in  St.  George's  Hospital,  and  for  the  se- 
cond of  which  I  am  indebted  to  my  friend 
Mr.  Henry  Earle,  of  St.  Bartholomew's 
Hospital,  aiford  examples  of  this  disease, 
and  of  the  extensive  mischief  to  which  it 
may  give  rise. 


CASiE  Lli. 

Edward  Griffiths,  forty-live  years  of 
age,  was  admitted  into  St.  George's  Hos^ 
pital  on  the  15th  of  April,  1818,  on 
account  of  an  abscess,  which  presented 
itself  in  the  left  groin.  He  said,  that 
about  four  months  before  his  admission, 
he  had  been  seized  Avith  pain  in  the 
loins  and  that  the  tumor  in  the  groin 
had  shewn  itself  about  six  weeks  after 
the  commencement  of  the  pain. 

He  was  directed  to  remain  constantly 
in  tbe  horizontal  position;  and  in  a  short 
time   the  tumor  formed  by  the  abscess 


(     269     ) 

in  the  groin  disappeared,  and  another 
shewed  itself  over  the  left  os  innomi- 
natum.  On  the  15th  of  May,  this  ab- 
scess was  opened,  and  about  forty  ounces 
of  pus  were  discharged.  After  this,  he 
gradually  sunk;  and  died  worn  out  by 
a  profuse  suppuration  on  the  19th  of 
August  following. 

On  dissection,  it  Avas  found  that  the 
cancellous  structure  of  all  the  dorsal  and 
lumbar  vertebrae  was  of  a  dark  red  colour, 
and  softer  than  natural,  so  that  they 
might  be  cut  with  a  common  scalpel,  or 
even  crushed  by  the  pressure  of  the 
thumb  and  fingers. 

Tlie  opposite  surfaces  of  the  bodies  of 
the  second  and  third  lumbar  vertebrre, 
and  of  the  cartilage  betwen  them,  at  the 
posterior  part,  were  extensively  destroyed 
by  ulceration.  Anteriorly,  the  bones  and 
the  intervertebral  cartilage  were  entire, 
and  the  latter  was  in  a  perfectly  natural 
state,  but  the  bones  throughout  were  of 
a  dark  and  ahuost  black  colour. 


(     270     ) 


On  one  side  of  the  body  of  the  twelfth 
dorsal  vertebra,  there  was  a  small  ulcer- 
ated spot,  forming  an  opening  which  ex- 
tended itself  into  a  small  cavity  in  the 
centre  of  the  bone.  This  bone  was  also 
of  a  black  colour;  but  the  intervertebral 
cartilages  belonging  to  it,  as  well  as  the 
intervertebral  cartilages  connected  with 
the  other  vertebrae,  were  in  a  perfectly 
natural  state. 

The  abscess  had  originated  in  the  ca- 
rious surfaces  of  the  second  and  third 
lumbar  vertebrEe,  and  had  extended  itself 
ibehind  the  left  psoas  muscle,  as  low  as 
the  upper  and  anterior  part  of  the  left 
thigh,  where  it  made  a  turn  backwards 
on  the  inside  of  the  tendon,  and  thus 
made  its  way  to  the  place  where  it  was 
opened  on  the  posterior  part. 

The  ribs  were  throughout  unusually 
vascular  and  brittle,  so  that  they  might 
be  broken  by  the  slightest  force.  There 
were  vomicae  in  the  lungs,  and  tubercles 
in  the  liver. 


(     271     ) 

CASE  LIII. 

Henry  Shaw,  seventeen  years  of  age, 
eonsulted  Mr.  Earle  in  N^ovember,  1816, 
on  account  of  a  complaint,  which  had 
begun  about  three  months  before,  and  of 
which  the  following  were  the  most  re- 
markable symptoms. 

He  had  frequent  attacks  of  pain  in  the 
head,  attended  with  giddiness.  Occa- 
sionally he  had  fits,  in  which  he  was  for  a 
short  time  insensible,  with  a  spasmodic 
action  of  some  of  the  muscles  of  the 
neck.  The  right  eye  was  amaurotic,  and 
there  was  constant  tinnitus  aurium.  His 
mental  faculties  were  for  the  most  part 
unimpaired. 

By  Mr.  Earle's  directions,  he  was  cup- 
ped; purgatives  were  administered,  and 
he  was  kept  under  the  influence  of  mer- 
cury during  six  weeks,  at  the  end  of 
which  time  his  symptoms  had  nearly 
disappeared. 

About  the  end  of  May,  1817,  he  went 


(      272      ) 

oa   a  visit  into   the   country,  and  while 
there    he    one    day    tripped   and   fell   in 
crossing  the  room.     Another  set  of  symp- 
toms now  sliewed  themselves,  for  which 
he  was  brought  to  London.     At  this  time 
he    had    pain   in    the   back   and    in    the 
right  side,   shooting  in  the  direction  of 
the    costal   nerves.     He   was   subject  to 
severe  cramps  in  the  stomach,  his  bowels 
were    irregular;   and   he   breathed   with 
difficulty.     He  had  cramps  in  his  lower 
limbs,  and  his   locomotive  powers  were 
impaired,  though  there  was  no  actual  pa- 
ralysis   of    the    muscles.      His    general 
health  was  much  deranged.     On  examin- 
ing the    spine,   Mr,   Earle  discovered  a 
curvature,   of  which   the   convexity  was 
turned  backwards,   occupying  about  the 
three  middle   dorsal  vcrtebra3,  and    this 
was  attended  with  a  considerable   alter-» 
ation  in  the  form  of  the  chest.     He  was 
now    removed    into    St.    Bartholomew's 
Hospital,  where  Mr.  Earle  directed  him 
to   remain   constantly  in  the  horizontal 


(     273     ) 

position,  and  an  issue  was  made  with 
caustic  on  each  side  ot*  the  spine.  In  a 
short  time  lie  lost  the  cramps  of  his 
lower  extremities,  hut  his  general  health 
continued  to  fail,  and  the  difficulty  of 
breathing  increased. 

In  the  middle  of  December  he  quitted 
the  hospital.  The  exertion  of  being 
moved  seemed  to  aggravate  the  disease. 
He  was  seized  with  numbness  of  the  left 
leg  and  thigh;  the  dyspnoea  became 
worse;  and  he  sunk  and  died  in  con- 
vulsions on  the  23d  of  December,  1817. 

On  dissection,  the  arachnoid  mem- 
brane was  found  opaque  and  thickened. 
A  large  tumor,  of  almost  cartilaginous 
hardness,  occupied  the  anterior  lobe,  and 
a  similar  one  the  posterior  lobe,  of  the 
right  hemisphere  of  the  cerebrum;  and 
a  third  tumor  occupied  the  greater  part 
of  the  right  lobe  of  the  cerebellum.  The 
ventricles  were  distended  with  water. 

The  riglit  lung  Avas  studded  with  tuber- 
cles, and  adhered  universally  to  the  pleura 

36 


(     274     ) 

costalis.  A  large  abscess  occupied  the 
posterior  mediastinum,  at  the  bottom  of 
which,  tlie  bodies  of  two  of  the  vertebrae, 
together  with  the  intervertebral  cartilage 
between  them,  were  found  nearly  de- 
stroyed by  ulceration.  The  other  inter- 
vertebral cartilages  were  in  a  natural 
state,  but  the  bodies  of  the  vertebrae  were 
soft,  and  many  of  them  were  beginning 
to  ulcerate.  The  ribs  were  porous,  and 
their  cancelli  were  filled  with  a  curdly 
matter;  and  they  were  soft,  so  that  they 
might  be  easily  divided  with  a  common 
scalpel.  Four  of  the  ribs  were  separated 
from  their  attachment  to  the  sjiine,  and 
were  ulcerated  as  far  as  their  tubercles. 


There  is  no  reason  to  doubt,  that  in 
these  cases,  the  bones  were  the  parts 
primarily  affected.  Other  cases  occa- 
sionally are  met  with,  which  at  first  ap- 
pear to  be  of  a  similar,  but  which  are,  in 
reality,  of  a  different  nature.     Where  an 


(     275     ) 

abscess  has  formed  in  the  neighbouring 
soft  imparts;  or,  where  there  has  been  a 
large  aneurysm  of  the  descending  aortaj 
and  wliere  a  tumor  produced  by  one  or 
other  of  these  causes,  or  in  any  other 
way,  has  long  pressed  on  the  bodies  of 
the  vertebrae,  the  bones  become  ulcerated, 
but  not  the  cartilages  between  them,  and 
the  former  are  ultimately  in  a  greater 
or  less  degree  consumed,  while  the  latter 
remain  projecting  almost  of  their  natural 
size.  In  such  cases,  where  the  spine  is 
carious,  in  consequence  of  disease  begin- 
ning external  to  it,  the  symptoms  are  not 
the  same  as  where  it  has  begun  in  the  spine 
itself.  For  the  most  part,  the  affection 
of  the  spine  is  not  suspected  during  the 
patient's  lifetime.  After  death,  the  bones 
are  found  of  their  natural  texture  and 
hardness;  and  it  is  easy  to  trace  the  ori- 
gin of  the  disease  in  the  neighbouiing 
soft  parts. 


K      276      ) 

Sect.  II. 

On  the  Stjmptoins  of  Carles  of  the  Spine. 

As  these  two  diseases  of  the  spine 
correspond  in  this  respect,  that  they  ter- 
minate in  a  more  or  less  extensive  caries, 
it  may  be  expected  that  there  must  be  a 
certain  degree  of  resemblance  in  the 
symptoms  which  tliey  produce.  Tliis  re- 
semblance is  indeed  greater  than  where 
the  same  morbid  affections  take  place  in 
other  joints.  I  suspect,  that  that  disease, 
"which  has  its  origin  in  the  cancellous 
structure  of  the  bones,  is  more  imme- 
diately followed  by  suppuration,  than 
that  which  commences  in  the  form  of 
ulceration  of  the  intervertebral  cartilages; 
and  that  the  former  seldom  occasions  a 
destruction  of  the  vertebra  to  so  great  an 
extent  as  the  latter.  But  farther  tlian 
this,  nothing,  which  I  have  hitherto  ob- 
served enables  me  to  point  out  any  cir- 
cumstances, in  which  the    symptoms    of 


(      277      ) 

these  different  diseases  differ;  nor  do  I 
believe  (however  desirable  it  may  be  to 
do  so),  that  it  is  possible,  in  the  present 
state  of  our  knowledge,  to  distinguish 
them  from  each  other,  with  any  degree  of 
accuracy,  in  the  living  person.  Perhaps 
future  observations  may  tlirow  light  on 
this  important  subject.  In  the  mean 
time,  when  I  speak  of  the  symptoms  of 
caries  of  the  spine,  it  is  to  be  understood, 
that  the  observations  which  I  make,  are 
(as  far  as  I  know)  applicable  to  either  one 
or  other  of  those  diseases,  in  which  the 
caries  originates. 

It  is  evident,  that  two  orders  of  symp- 
toms may  be  the  result  of  caries  of  the 
spine: — Ist,  Those,  Avhich  are  the  imme- 
diate consequence  of  the  morbid  condition 
of  the  vertebrae  themselves,  and  of  the 
intervertebral  cartilages.  2dly,  Those, 
which  arise  from  pressure  on  the  spinal 
marrow,  or  from  irritation  propagated  in 
some  way,  or  another,  to  this  important 
part  of  the  nervous  system.     I  believe,  it 


(      278      ) 

will  be  found,  that,  wlien  the  disease  is 
situated  above  tlie  lumbar  region,  it 
almost  constantly  happens,  that  these  two 
gets  of  symptoms  are  combined,  whereas 
when  the  vertebi-ai  of  the  loins  are  alone 
affected,  the  latter  set  of  symptoms  are 
generally  w  anting.  Perhaps,  this  may  be 
accounted  for,  partly  from  the  greater 
magnitude  of  the  bodies  of  the  lumbar 
vertebrsej  in  consequence  of  which,  a 
much  more  extensive  caries  is  necessary 
to  produce  the  same  quantity  of  incur- 
vation here,  than  elsewhere;  and  partly, 
from  the  circumstance  of  the  spinal  mar- 
row here  terminating  in  the  bundle  of 
nerves  belonging  to  the  lower  extremi- 
ties; which  possess  a  different  structure, 
exercise  different  functions,  and  are  pro- 
bably of  a  less  susceptible  nature  than  the 
spinal  marrow^  itself. 

Caries  of  the  lumbar  vertebrse  usually 
occasions  a  pain  in  the  loins,  which,  after 
a  longer  or  shorter  period  of  time,  is 
followed  by  an  external  abscess,  shewing 


(      279      ) 

itself  in  the  groin,  or  in  some  other  situa- 
tion, and  it  constitutes  one  of  the  diseases, 
which  are  confounded  with  each  other, 
under  tiie  name  of  Psoas  or  Lumbar  ab- 
scess. 

The  symptoms,  which  are  produced  in 
those  other  cases,  where  caries  is  followed 
by  curvature  of  the  spine,  and  affection  of 
the  spinal  marrow;  have  been  described 
at  length  in  the  works  of  former  writers, 
(more  especially  in  the  able  and  eloquent 
dissertations  of  Mr.  Pott,)  and  it  is  unne- 
cessary for  me  to  repeat  what  has  been  al- 
ready given  to  the  world  by  others.  I 
shall  therefore  only  advert  to  certain 
points  in  the  history  of  the  disease, 
which  some  of  my  own  observations  may 
tend  to  illustrate. 

The  curvature  of  the  spine,  which  this 
disease  produces,  cannot  take  place  until 
the  caries  has  made  considerable  pro- 
gress; and  hence,  although  it  furnishes  an 
excellent  diagnostic  mark  of  the  disease 
in  its  most  advanced  stage,  it  affords  the 


(     280     ) 

surgeon  no  assistance  whatever  at  tliat 
early  period,  when  the  diagnosis  is  of  the 
most  importance.  Previous  to  the  ap- 
pearance of  the  curvature,  the  symptoms 
are  not  unfrequently  very  equivocal;  so 
that  the  real  nature  may  often  be  over- 
looked by  a  careless  practitioner;  and 
sometimes  even  by  the  most  accurate  and 
minute  observer.  A  pain,  and  some  de- 
gree of  tenderness  in  that  part  of  the 
spine,  where  the  disease  has  begun;  a 
sense  of  constriction  of  the  chest;  an 
uneasy  feeling  at  tlie  pit  of  the  stomach, 
and  of  the  whole  abdomen;  a  disturbed 
state  of  the  functions  of  the  alimentary 
canal,  and  of  the  urinary  bladder;  a  sense 
of  weakness  and  aching,  and  occasional 
cramps  of  the  muscles  of  the  extremities; 
one  or  more  of  these  symptoms,  accord- 
ing to  the  part  of  the  spine,  which  is  af- 
fected, and  other  circumstances,  are  in 
most  instances  met  with  before  the  form 
of  the  back  has  undergone  any  alteration. 
But  it  is  obvious,  that  symptoms  very 


(    281    ; 

similar  to  tliese  may  arise  from  other 
causes;  and  hence  practitioners  are  liable 
to  be  led  into  error.  Many  cases  also 
occur,  in  which  these  symptoms  have 
been  so  slight,  that,  although  the  patient 
has  recollected  them  afterwards,  he  did 
not  experience  sufficient  inconvenience 
at  the  time  to  be  induced  to  notice  them, 
•and  I  have  even  known  some  instances, 
in  which  they  are  altogether  wanting,  so 
that  there  has  been  no  suspicion  of  any 
complaint  existing  previous  to  the  actual 
discovery  of  the  curvature. 

In  the  greater  number  of  cases,  which 
have  come  under  my  observation,  the 
curvature  of  the  spine  has  been  first  no- 
ticed about  six  months  after  the  com- 
mencement of  the  other  symptoms.  In 
one  case  only  the  interval  was  as  long  as 
two  years. 

In   general,  the    curvature  is    at  first 

only  just  perceptible;  and  by  degrees  it 

becomes  more  distinct.     In  one  instance, 

ike  patientj  who  had  made  no  previous 

87 


(     282     ) 

complaint,  immediately  after  some  sliglit 
exertion,  experienced  a  sudden  pain,  as  if 
something  had  given  Tvay  in  the  back, 
and  immediately  afterwards  lost  the  use 
of  her  lower  limbs,  and  observed  that  the 
spinous  process  of  one  of  the  lower  dorsal 
vertebrse  made  an  angular  projection.  In 
another  patient  a  similar  circumstance 
occasioned  the  same  sensation,  and  was 
followed  by  numbness  of  the  legs  and 
thighs,  and  paralysis  of  the  bladder;  but 
not  by  any  evident  curvature.  Of  course, 
we  must  suppose,  that  the  disease  had 
been  making  progress,  before  the  occur- 
rence of  the  trifling  accident,  which  first 
induced  its  symptoms. 

The  distortion  of  the  spine  in  these 
cases  is  usually  of  a  peculiar  kind,  and 
such  as  nothing  can  produce  except  the 
destruction  of  the  bodies  of  one  or  more 
vertebrte.  The  spine  is  bent  forward,  so 
as  to  form  an  angle  posteriorly;  and 
although  the  destruction  of  the  vertebra 
may  be  the  sam^,  it  is  more  obvious  in 


(      283     ) 

isome  parts  of  the  spine,  than  it  is  in 
others.  For  example,  the  spinous  pro- 
cesses in  the  middle  of  the  back  being 
long,  and  projecting  downwards,  the  ele- 
vation of  one  of  these  must  occasion  a 
greater  prominence,  than  that  of  one  of 
the  spinous  processes  of  the  neck,  which 
are  short,  and  stand  directly  backwards. 

Curvature  of  the  spine  in  the  direction 
forwards,  may  arise  from  other  causes, 
as  a  weak  condition  of  the  muscles,  or  a 
rickety  afl^ection  of  the  bones.  In  ge- 
neral, in  such  caseSj  the  curvature  occu- 
pies the  whole  spine,  which  assumes  the 
form  of  the  sescment  of  a  circle.  At 
other  times,  however,  it  occupies  only  a 
portion  of  the  spine,  usually  that,  which 
is  formed  by  the  superior  lumbar,  and 
inferior  dorsal  vertebrae;  as  I  have  ascer- 
tained, not  only  by  examinations  during 
life,  but  by  dissection  after  death.  Here 
the  curvature  is  always  gradual;  never 
angular;    and    thus    it    may   be   distin- 


(      284     ) 

guislied  from  the  curvature  arising  from 
caries.  Nevertlieless,  I  am  satisfied,  that 
those  different  kinds  of  curvature,  arising 
from  different  causes,  have  frequently 
been  confounded  with  each  other;  and 
that  some  of  the  cases,  which  have  been 
pubUshed  as  examples  of  caries  of  the 
spine,  and  in  which,  it  may  at  first  be  a 
matter  of  surprize,  that  so  complete  and 
so  speedy  a  cure  has  been  effected,  have 
in  reality  been  cases  of  an  entirely  differ* 
ent  malady.* 

I  believe  it  is  generally  supposed,  that 
the  lateral  distortion  of  the  spine  arises 
from  causes,  which  are  independent  of 
caries.  This  rule  however  must  not  be 
admitted  without  some  exceptions.  A 
slight  degree  of  lateral  curvature  is,  in 
some  instances,  the  consequence  of  caries. 


*  Some  excellent  observations  on  this  subject  are 
published  by  Mr.  Earle  in  the  Edinburgh  Medical 
Journal  for  January,  1815. 


I     285     ) 

Iriiis  was  observed  in  one  of  the  casei 
related  in  tlie  last  section,  and  the  ex- 
amination of  the  morbid  appearances 
explained  in  what  manner  the  lateral 
curvature  was  produced;  that  is,  by  the 
bodies  of  the  vertebrae  having  been  de- 
stroyed on  one  side,  to  a  greater  extent 
than  on  the  other. 

Mr.  Copeland*  has  observed  that  the 
symptoms,  which  take  place  in  this  dis- 
ease in  consequence  of  the  affection  of 
the  spinal  marrow,  are  not  always  con- 
fined to  the  parts  below,  as  might  be 
expected,  but  that  tliey  take  place  also 
in  those  parts,  which  are  above  the  ulcer- 
ated vertebrae*  This  is  an  important  ob- 
servation, and  I  have  had  opportunities 
of  ascertaining  it  to  be  correct.  When 
the  disease  has  been  situated  in  the  mid- 
dle or  lower  part  of  the  back,  I  have  not 
indeed  known  the  muscles  of  the  upper 


*  "  Observatioivs  on  the  Symptoms  and  Treatment 
of  Diseased  Spine,''  he.  by  Thomas  Copeliuid. 


(     286     ) 

extremities  to  be  paralytic,  but  it  is  not 
uncommon  under  these  circumstances, 
for  pains  in  the  arms  to  be  connected 
^vith  a  'paralytic  affection  of  the  legs  and 
thighs. 

I  haye  already  observed,  that  there  is 
reason  to  believe,  that  suppuration  takes 
place  at  an  earlier  period,  in  those  cases, 
where  the  disease  has  its  origin  in  the 
cancellous  structure  of  the  bone,  than 
where  it  begins  in  the  intervertebral  car- 
tilages. It  is  remarkable  in  some  cases 
of  this  last  description,  to  how  great  an 
extent  ulceration  will  sometimes  proceed, 
without  the  formation  of  abscess.  I  have 
known  as  many  as  three  bodies  of  yerte- 
brse  completely  destroyed,  and  the  disease 
to  have  lasted  many  years,  and  yet  matter 
has  not  been  formed;  a  fortunate  circum- 
stance for  the  patient,  as  the  chance  of 
his  recovery  is  much  greater  under  these, 
than  it  would  have  been  under  the  oppo- 
site circumstances.  In  whatever  part  of 
the  spine  the  disease  is  situated,  the  ab- 


(      287      ) 

^cess  is  likely  to  present  itself  in  tlio 
upper  and  anterior  part  of  the  thi^li;  but 
it  may  make  its  way  in  various  other  di- 
rections. Sometimes  it  takes  the  course 
of  the  spermatic  cord,  and  forms  a  tu- 
mor projecting  through  the  abdominal 
ring;  such  as  a  superficial  observer  might 
readily  mistake  for  a  hernia.  In  one  case, 
which  I  had  an  opportunity  of  examining 
after  death,  the  abscess  had  penetrated 
into  the  theca  vertebralis,  and  the  whole 
of  the,  spinal  marrow,  from  its  origin  to 
jts  termination,  was  bathed  in  pus. 

Sect.  III. 

On  the  Treatment, 

For  reasons  similar  to  those,  which  pre- 
vented my  entering  at  length  into  the  his- 
tory of  the  symptoms,  which  occur  in  cases 
of  caries  of  the  spine,  I  shall  make  but 
few  observations  on  the  methods  of  treat- 
ment, which  may  be  employed  for  its  re° 


(     288     ) 

lief.  Those,  which  have  heen  principally 
recommended,  are,  first,  a  state  of  perfect 
quietude  in  the  horizontal  position,  con- 
tinued for  a  long  period  of  time;  and,  se- 
condly, the  establisment  of  issues  made 
with  caustic  in  the  neighbourhood  of  the 
affected  vertehrse. 

I  should  imagine  that  no  one  will  be 
bold  enough  to  deny  the  prudence,  and 
that  but  few  will  deny  the  absolute  neces- 
sity, of  the  first  of  these  remedies. 
While  the  patient  is  in  the  erect  position, 
and  the  weight  of  the  head  and  other 
superincumbent  parts  is  pressing  the  ul- 
cerated surfaces  one  against  the  other,  it 
is  not  likely  that  the  progress  of  the  ul» 
Deration  can  be  checked,  and  it  is  highly 
probable  that  suppuration  will  be  induced. 
Concerning  the  advantage  to  be  derived 
from  issues,  there  may  perhaps  be  a 
greater  difference  of  opinion:  and  I  am 
well  aware,  that  some  of  the  most  ex- 
pej'ienced  practitioners  of  the  present 
day,  estimate  their  value  at  a  low  rate, 


(     289     ) 

It  is  not,  however,  very  easy  to  suppose 
that  3Ii'.  Pott,  and  others,  whose  opinion 
carries  with  it  mucli  authority,  should 
have  been  mistaken  so  Car  as  to  persevere 
during  a  series  of  years,  in  the  employ- 
ment of  a  remedy,  which  was  wholly  in- 
efficacious. If  issues  are  of  service,  uhere 
the  cartilages  of  the  hip  or  knee  are  ul- 
cerated, analogy  would  lead  us  to  expect, 
that  they  may  be  useful  also,  where  a  cor- 
responding disease  has  taken  place  in  the 
joints  of  the  vertebrre,  and  my  own  ex- 
perience has  certainly  tended  to  confirm 
this  expectation.  I  have  known  instances 
of  patients,  who  have  been  under  precisely 
the  same  circumstances  with  respect  to 
rest,  and  whose  symptoms  have  been 
manifestly  and  considerably  relieved  either 
immediately,  or  in  a  short  time,  after  the 
issues  had  been  made:  and  where  the 
caustic  has  been  occasionally  applied  to 
the  surface  of  the  issue  for  the  purpose  of 
keeping  it  open,  other  patients  have  in- 
formed me  that  "  they  have  uniformly 

38 


(     290      ) 

found  themselves  better  in  a  few  hours 
after  eueli  application."  At  the  saiue  time 
it  must  be  acknowledged,  tiiat  some  cnses 
occur,  in  which  the  caustic  issues  st<m 
to  be  productive  of  little  or  no  benefit. 
Piobably  it  is  with  diseases  of  the  ver- 
tebral joints,  as  it  is  with  those  of  the 
joints  of  the  extremities,  and  issues  n^ay 
be  useful  where  the  original  aftiction  is 
an  ulceration  of  the  intervertebral  carti- 
lages, and  they  may  be  of  donbti'ul  eifi- 
cacy  where  the  morbid  change  oi*  the 
cancellous  structure  of  the  bones  |  re- 
cedes the  ulceration.  If  this  be  cori'i  ct, 
the  difterence  of  opinion  on  t.e  subject 
of  issues  may  be  easily  exjlaiittd;  Jtud 
we  must  regret  the  more  that  we  are 
acquainted  w  ith  no  better  signs,  by  which 
these  two  varieties  of  disease  may  be  dis- 
tijiguished  in  tbe  living  person. 

Mr.  Pott  has  depiecated  in  slrorig 
terms,  the  employment,  in  these  ca^es, 
of  Jill  those  instruments,  and  other  me- 
chanical contrivances,  whicii  have   been 


(     291     ) 

invented  and  recommended  for  distor- 
tions of  tike  spine;  and  we  cannot  but 
believe,  that  any  attempts  to  elongate  and 
restore  its  fii^nre,  by  forcibly  separating 
the  ulcerated  surfaces  of  bone,  which  are 
in  eontact,  and  disposed  to  cohere,  must 
be  liighly  injurious.  But  it  is  also  phiin, 
that  the  disease  is  lii^ely  to  be  aggravated 
by  the  pressure  of  the  superincumbent 
parts,  when  the  patient  is  in  the  erect 
position;  and  if  instruments  be  em- 
ployed, simply  for  the  purpose  of  sup- 
porting the  column  of  the  vertebrae,  and 
taking  otf  the  weight  of  the  head  from 
the  ulcerated  surfaces,  they  cannot  be 
liable  to  the  same  objections,  as  when 
they  are  applied  with  otiier  views,  and  it 
is  reasonable  to  expect  that  they  may  be 
provluetive  of  advantage  to  the  pa  ient. 
Tiiey  certainly  ought  never  to  supersede, 
in  the  first  instance,  the  constant  main- 
tenance of  the  hoi'izontal  posture;  but  I 
am  exceedingly  mistaken,  if  T  have  not 
seen   them  of  much  service,   when  the 


(     292     ) 

patient  lias  made  a  certain  decree  of  pro- 
gress towards  recovery;  and  when  oiicum- 
stances  liave  made  it  desirable,  that  he 
should  begin  to  sit  up,  during  a  part  of 
the  twentj'-four  hours. 

In  tliose  cases^  in  which  a  cure  is  sup- 
posed to  have  been  effected,  it  generally 
happens,  that  the  cari(ms  vertebrae  are 
united  with  each  other  by  bony  sub- 
stance, which  is  laid  on  in  a  considerable 
mass  on  their  external  surface.  But  I 
have  seen  other  cases,  in  which  anchy- 
losis has  never  taken  place.  The  pro- 
gress of  the  disease  has  been  stopped; 
the  surfaces  of  the  vertebrae,  which  had 
been  affected,  have  been  partially  in  con- 
tact, bnt  no  actual  cohesion  has  taken 
place  between  them,  and  they  have  re- 
mained, in  a  certain  degree,  moveable 
on  each  other.  Under  these  circum- 
stances, an  instrument  judiciously  applied 
will  be  useful,  not  only  by  affording  sup- 
port to  the  spine;  but  also  by  preventing 
the  weight,  and  motion  of  the  parts  above, 


(  293     ) 

from  exciting  a  recurrence  of  the  caries. 
A  patient,  in  whom  there  had  heen  ex- 
tensive destruction  of  the  bodies  ot*  the 
dorsal  vertebra?,  but  who  had  been  for 
some  years  tree  from  all  symptoms  of  his 
complaint,  left  ofl'  an  instrument,  Avhich 
he  had  been  in  the  habit  of  wearing.  In 
the  course  of  a  few  months,  he  was  seized 
with  pains  in  his  lower  limbs,  and  a  tu- 
mor, evidently  formed  by  a  large  abscess, 
has  lately  presented  itself  in  the  loins,  so 
that  there  is  reason  to  believe,  tliat  his 
having  omitted  to  wear  the  instrument 
has  been  followed  by  a  recurrence  of  the 
original  disease,  in  an  aggravated  form. 
In  making  these  remarks,  however,  I 
do  not  mean  to  affirm,  that  the  cases 
in  which  it  is  right  to  call  in  the  aid 
of  mechanical  contrivances  are  of  fre- 
quent occurrence,  and  I  must  repeat  that 
they  ought  never  to  be  employed  for  the 
purpose  of  elongating  the  spine,  and  cor- 
recting the  deformity. 

Whatever  it  is  possible  to  do  towards 


(     294     ) 

attaining  tliis  last  object  will  be  effected, 
by  the  patient  being  made  to  continue 
for  a  long  time,  in  the  supine  position,  on 
a  liorizontal  board.  The  curvature  may 
perhaps,  by  these  means,  be  in  a  sKght 
degree  diminished.  At  any  rate,  if  the 
curvature  has  taken  place  in  a  child,  it 
will  be  less  perceptible  when  he  is  grown 
up.  I  have  never  seen  a  case,  where 
the  curvature  has  been  very  distinct,  and 
where  it  has  wholly  disappeared;  and  it 
is  not  easy  to  belicAe  that  this  can  ever 
happen,  if  it  be  true,  that  portions  of 
bone  elsewhere,  which  have  been  de- 
stroyed, are  never  regenerated,  unless,  the 
whole,  or  the  greater  part  of  the  perios- 
teum has  remained  unhurt.  To  the  best 
of  my  knowledge,  no  specimens  exist  in 
anatomical  museums,  in  which  the  S(  ace 
between  the  carious  vertebrae  has  been 
filled  up  by  new  bone. 


CHAP.  VII. 

ON  SOME  OTHER  DISEASES  OF  THE  JOINTS. 

In  the  present  chapter  it  is  intended  to 
notice,  in  a  brief  manner,  some  other  af- 
fections of  the  joints,  which  either  occur 
more  rarely  than  those  ah-eady  described, 
or  concerning  which  I  have  but  few  re- 
marks to  offer,  in  addition  to  what  has 
been  said  by  others. 


1.  I  have  seen  a  very  few  cases,  in 
which  common  inflammation  had  taken 
place  in  the  articulating  extremity  of  a 
bone,  and  an  abscess  had  formed  and 
burst  into  the  joint.  In  such  cases,  on 
dissection,  the  bone  is  found  possessing 
its  natural  texture  and  hardness,  but  it  is 
of  a  dark  colour,  and  usually  has  a  fcptid 
smell.     Sometimes  there  is  a  fresh  form- 


(     296     ) 

ation  of  bony  matter  in  consequence  of 
inflaniiuation  and  ossification  of  tlie  pe- 
riosteum: and  this  constitutes  tlie  only 
species  of  diseased  joint,  which  has  come 
under  my  own  observation,  in  which  an 
actual  enlargement  of  bone  has  taken 
place.  Where  the  soft  parts  of  a  joint 
are  considerably  thickened,  a  feelii»g  is 
sometimes  given  to  the  hand,  as  if  the 
bones  tliemselves  were  increased  in  size, 
but  ray  friend,  Mr.  Lawrence,  some  years 
ago  observed,  and  pointed  out  that  this 
feeling  is  deceptive.* 

2.  I  have  known  an  instance,  in  which 
without  anj'  obvious  cause,  a  large  por- 

*  Since  the  last  chapter  was  sent  to  the  press,  I  have 
had  an  opportunity  of  examining  a  dise.i'-ec]  spine, 
m  which  there  was  an  extensive  caries  originating, 
as  it  appeared,  in  common  inflammation  of  the  bodies 
of  the  vertebrae.  The  hones  retained  theii  ordinary 
hardness;  but  were  oi  a  hlack  colour,  and  although 
one  of  the  intervertebral  cartilages  was  dcsiroyed,  it 
was  manliest  from  the  state  o  the  neighbouring 
vertebrge.  that  the  disease  had  begun,  not  in  the 
cartilaginous,  but  in  the  bony  texture. 


(     297      ) 

tioii  of  the  head  of  the  tibia  died  and 
exfoliated,  and  the  destruction  of  the 
knee-joint  was  the  consequence. 

Another  case  occurred  somewhat  cor- 
responding to  the  last.  In  examining 
the  body  of  a  patient  in  the  hospital, 
who  had  died  labourino:  under  an  aftec- 
tion  of  the  spine,  I  found  the  bodies  of 
no  less  than  six  of  the  dorsal  yertebrje 
dead,  and  undergoing  the  process  of  ex- 
foliation. Five  of  them  were  entire,  and 
the  sixth  was  broken  into  several  pieces. 
The  intervertebral  cartilages  had  wholly 
disappeared.  The  patient  attributed  his 
complaint  to  some  unusual  exertion  in 
lifting  a  heavy  weight. 


3.  The  loose  cartilaginous  substances, 
which  are  sometimes  found  in  the  joints, 
have  been  so  frequently  described  by 
writers,  that  I  can  have  but  few  observa- 
tions to  offer  respecting  them. 

39 


(     298     ) 

1  believe  it  is  generally  supposed,  that 
these  loose  bodies  have  their  origin  in 
coagulable  lymph,  which  has  been  effused 
from  inflammation,  on  the  inner  surface 
of  the  synovial  membrane,  and  which 
aftei  wards  has  become  vascular.  But  in 
the  majority  of  cases  which  I  have  met 
with,  no  symptoms  of  inflammation  pre- 
ceded their  formation,  and  hence  it  is 
probable,  that  in  some  instances,  they  are 
generated  (like  other  tumors)  in  conse- 
quence of  some  morbid  action  of  a  differ- 
ent nature. 

They  appear  to  be  situated  originally, 
either  on  the  external  surface,  or  in  the 
substance  of  the  synovial  membrane,  since, 
before  they  have  become  detached,  a  thin 
layer  of  the  latter  may  be  traced  to  be 
reflected  over  them. 

My  own  experiemce  is  much  in  favour 
of  the  removal  of  loose  cartihiges  by  an 
incision  of  the  joint,  jirovided  that  this 
bedoncin  a  cauiious  and  pi-udent  man- 
ner.    The  ^patient  should  be  kept  in  a 


(      299     ) 

State  of  the  most  perfect  quietude  for  two 
or  three  days   preceding,  and  for  several 
days  after  the  operation.     The   cartilage 
having  been  well  fixed,  the  different  parts 
over  it  should  be,   slowly,  and  separately, 
divided  until  it  is  exposed.     The  wound 
of  the  synovial  membrane  may  be  dilated 
by  means   of  a   probe-pointed   bistoury, 
so  that  it  may  be  enough  to  allow  of  the 
cartilage  being  extracted  with  a  tenacu- 
lum:   and   the    cut    edges    of   the    skin 
should   be  instantly   placed    iu    contact 
with  each  other,  and  secured  by  means 
of  adhesive  plaster.     I  attended  a  gen- 
tleman, who  laboured  under  this  trouble- 
some  complaint,  and  in  whom  the  loose 
bodies  not  unfrequently   slipped  between 
the  articulating  surfaces  of  the  knee,  occa- 
sioning an  almost  immediate  swelling  of 
the  joint,  with  the  most  excruciating  pain, 
and   teiiderness,  and  much  symptomatic 
fever.      In   one   instance,    more   than    a 
month   elapsed,   before  these   symptoms 
had  subsided.     These  circumstances  are 


(    800    ; 

noticed,  because  they  prove,  that,  in  this 
patient,  there  was  a  considerable  disposi- 
tion to  inflammation;  yet,  by  attending 
to  the  precautions  above  mentioned,  as 
many  as  five  loose  cartilages  were  ex- 
tracted, by  three  difierent  operations, 
without  the  slightest  inconvenience  from 
any  one  of  them. 

I  have  seen  two  cases,  in  Avhicli  the 
loose  bodies  were  of  a  different  nature, 
and  had  a  different  origin,  from  those, 
which  are  commonly  met  with.  It  occa- 
sionally happens,  that,  from  some  morbid 
action,  a  bony  ridge  is  formed,  like  a 
small  exostosis,  round  the  maj'gin  of  the 
cartilaginous  surfaces  of  the  joint.  In 
the  two  cases,  to  which  I  allude,  this 
preternatural  growth  of  bone  had  taken 
place,  and  in  consequence  of  the  motion 
of  the  parts  on  each  other,  poitions  of  it 
had  been  broken  off,  and  lay  loose  in  the 
cavity  of  the  joint. 


(     30A      ) 

4.  I  have  seen  one  case,  in  wbicli  there 
was  a  large  tumor  of  the  knee,  apparently 
belonging  to  that  class  of  diseases,  to 
which  the  name  of  Fungus  llsernatodes 
has  been  given  by  Mr.  Hey,  and  of  Me- 
dullury  Sarcoma  by  3Ir.  Abernethy.  The 
patient  would  not  submit  to  amputation, 
and  I  had  no  opportunity  of  ascertaining 
after  death  in  what  texture  the  morbid 
growth  originated. 

CASE  LIV 

5.  A  lady,  in  the  year  1808,  first  observed 
a  swelling  in  the  upper  part  of  one  knee, 
which  was  unattended  by  pain;  and 
which  increased  slowl}^,  but  uniformly. 
In  the  course  of  three  years  it  had  at- 
tained so  inconvenient  a  mai>'nitude.  that 
the  patient  was  inducted  to  consent  to  the 
removal  of  tbe  limb.  Mr.  Thomas,  un- 
der whose  care  this  lady  was,  performed 
the  operation,  and  allowed  me  afterwards 
to  examine  the  amputated  joint. 


(      302      ) 

The  tumor  occupied  the  upper  part  of 
the  knee,  beginning  at  the  edge  of  the 
cartilaginous  surface,  and  extending  about 
three  or  four  inches  up  the  lower  part  of 
the  thigh.  It  was  interposed  between 
the  muscles  and  the  bone  of  the  thigh, 
so  that  the  former  were  seen  expanded 
over  it.  It  wa&  of  a  greyish  white 
colour;  composed  of  fibres  of  a  gristly 
semitransparent  substance,  with  osseous 
matter  intermixed  w  ith  it,  and  about  two 
inches  in  thickness  on  each  side  of  the 
femur.  At  the  upper  part  it  was  seen 
distinctly  originating  in  the  periosteum; 
at  the  lower  part,  the  periosteum  could 
not  be  traced,  and  the  structure  of  the 
bone  was  continued  into  that  of  the  tu- 
mor. The  cartilages  and  ligaments  of 
the  joint  were  free  from  disease.  On 
the  external  surface  of  the  synovial  mem- 
brane, unconnected  with  the  diseased 
structure  above,  there  were  three  or  four 
flattened  bodies,  each  of  about  the  size 
of  a  kidney  bean,  of  a  white  colour,  and 


(     303     ) 

of  a  texture  somewhat  softer  than  that  of 
cartilage.  The  synovial  membrane  itself 
was  free  from  disease. 

There  can  be  no  doubt   that   in   this 
case,  the  original  disease  was  the  osteo- 
sarcomatous    tumor,    originating   in    the 
periosteum  of  the  femur.     The  circum- 
stance of  the  other  tumors  being  found 
connected  with  the  synovial  membrane, 
although  the  intermediate   parts  were,  to 
all  appearance,  in  a  healthy  state,  is  re- 
markable, but   something  corresponding 
to  this  may  be  observed  in  other  diseases. 
For  example,  when  a  scirrhus  has  formed 
in  the  gland  of  the  breast,  it  is  not  un- 
usual to  find  small  tubercles  of  a  similar 
structure  in  the  skin  over  it,  at  various 
distances  from  each  other,  although  the 
intermediate  adipose  substance,   as   well 
as  the  portions  of  skin  between   the  tu- 
bercles themselves,  exhibit  no  marks  of 
disease, 

I  met  with  another  case,  in  which  the 
patient  appeared  to  labour  under  an 
enormous  tumor  of  the  hip.     It  was  as- 


(     304     ) 

certained  by  dissection,  that  the  hip  itselfi 
was  free  from  disease,  and  that  the  en- 
largement was  formed  by  an  osteo- 
sareomatous  growth  from  the  periosteum 
of  the  upper  extremity  of  the  femur.* 


6.  The  effects  pf  gout  on  the  joints  are 
very  remarkable.  The  cartilages  ai'e  ab- 
sorbed; the  exposed  surfaces  of  bone 
are  partly,  or  entirely,  encrusted  with 
a  white  earth^^  matter,  which  1  conclude 
to  be  urate  of  soda;  and  sometimes  they 
have  the  appearance  of  being  formed  into 
grooves,  as  if  they  had  been  worn  by  their 
friction  on  each  other.  In  some  cases 
repeated,  and  long-continued  attacks  of 
gout  occasion  complete  ancliylosis. 

*  Mr.  Russel  in  his  "  Treatise  on  <he  Morbid  Af- 
fections of  the  Knee,"  has  given  an  account  of  what 
he  terms  "  an  uncommon  disease'''  of  this  joint.  If  I 
am  not  mistaken,  whoever  peruses  the  history,  which 
Mr.  Russel  has  given,  will  be  of  opinion  that  some 
of  the  cases,  trom  which  he  has  drawn  his  observa- 
tions, wt- re  Oi  a  similar  nature  to  those,  which  are 
described  above. 


CHAP.  VIII. 

ON  INFLAMMATION  OF  THEBURSiE  MUCOS.Ti.^ 

Sect.  I. 

Mistory  and  Symptoms  of  this  Disease, 

The  synovial  membranes,  whicli  consti- 
tute the  burssc  mucosse,  very  nearly  re- 
semble in  their  structure  and  functions, 
those  which  line  the  articular  cavities; 
and  hence,  it  must  be  considered  as  a  re- 
markable circumstance,  that  the  former 
should   not  be  subject  to   that   peculiar 


*  I  include,  under  this  head,  the  itiembranes  form- 
ing the  sheaths  of  the  tendons,  which  have  the  same 
structure,  answer  a  similar  purpose,  and  cannot,  with 
propriety,  be  distinguished  from  the  other  bursse.  I 
adopt  the  name  of  bursa;  mitcosce^  because  it  is  in  ge- 
neral use,  although  it  ill  expresses  the  functions  oi 
organs  to  which  it  is  applied. 

40 


(     306      ) 

morbid  alteration  of  structure,  which  oc- 
curs in  the  latter,  and  which  has  been 
described  in  another  part  of  this  volume. 
Inflammation  of  the  bursse  mucosae  is 
marked  by  nearly  the  same  characters, 
and  (allowance  being  made  for  the  dif- 
ference of  tlie  parts,  with  which  they  are 
connected)  produces  nearly  the  same  re- 
sults with  inflammation  of  the  synovial 
membranes  of  tlie  joints.  In  the  greater 
number  of  instances  it  occasions  an  in- 
creased secretion  of  synovia.  In  other 
cases,  the  bursa  is  distended  by  a  some- 
what turbid  serum,  with  portions  of 
coagulable  l^niiph  floating  in  it.  Oc- 
casionally it  terminates  in  tlie  formation 
of  abscess.  Sometimes  the  membrane 
of  the  bursa  becomes  thickened,  and 
converted  into  a  gristly  substance.  I 
have  seen  it  at  least  half  an  inch  in 
thickness,  with  a  small  cellular  cavity  in 
the  centre  containing  synovia.  At  other 
times,  although  the  inflammation  has 
continued  for   a  very   long  period,  the 


(    ^^'^    ) 

Ttnembrane  of  the  bursa  retains  its  ori- 
ginal structure. 

Inflammation  of  the  bursa?  mucosae 
may  be  the  consequence  of  pressure,  or  of 
other  local  injury.  It  may  arise  from  the 
too  great  use  of  mercury,  from  rheuma- 
tism, or  from  some  other  constitutional 
Affection:  and  in  such  cases  it  is  fre- 
quently combined  with  inflammation  of 
the  synovial  membranes  of  the  joints. 
Sometimes  it  has  the  form  of  an  acute, 
but  more  frequently  it  has  that  of  a 
chronic  inflammation. 

The  inflamed  bursa  forms  a  tufnor, 
more  or  less  distinct,  according  to  its 
situation;  more  or  less  painful,  accord- 
ing to  the  character  of  the  inflammation. 
If  the  bursa  be  superficial,  the  fluc- 
tuation of  fluid  within  it,  is,  in  the 
first  instance,  very  perceptible:  and, 
imder  these  circumstances,  if  thej  inflam- 
mation be  considerable,  it  extends  to  the 
surrounding  parts,  and  occasions  a  red- 
ness of  the  skin.     When  the  disease  has 


(     308      ) 

existed  for  a  certain  period  oF  time,  it 
generally  happens,  tliat  tjie  fluid  is  less 
distinctly  to  be  felt  on  account  of  the 
membrane  having  become  thiekenedj^ 
and,  occasionally,  this  takes  place  to  such 
an  extent,  that  the  tumor  exhibits  all 
the  characters  of  a  hard  solid  substance, 
of  which  the  fluid  contents  are  imper- 
ceptible. 

When  the  inflammation  is  of  long- 
standing, it  is  not  unusual  to  find  float- 
insc  in  the  fluid  of  the  bursa  a  number 
of  loose  bodies,  of  a  flattened  oval  form, 
of  a  light  brown  colour,  with  smooth 
surfaces,  resembling  small  melon  seeds 
in  appearance.  There  seems  to  be  no 
doubt  that  these  loose  bodies  have  their 
origin  in  the  coagulable  lymph,  which 
wa,s  eflnsed  in  the  early  stage  of  the 
disease:  and  1  hare  had  opportunities, 
by  the  examination  of  several  cases,  to 
tra*e  the  steps  of  their  gradual  formation. 
At  first  the  coagulable  lymph  forms  irre- 
gular masses   of  no   determined    shape: 


(     309      ) 

afterwards  by  the  motion  and  pressure 
of  the  contiguous  parts,  it  is  broken 
down  into  smaller  portions.  These,  by 
degrees,  become  of  a  regular  form,  and 
assume  a  firmer  consistence:  and  at  last 
they  terminate  in  the  flat  oval  bodies, 
which  have  been  just  described. 

When  inflammation  of  a  bursa  mucosa 
ends  in  suppuration,  the  abscess  some- 
times makes  its  way  directly  to  the  sur- 
face of  the  skin,  and  bursts  externally 
but  I  suspect,  that  in  other  cases  the 
matter  in  the  first  instance  escapes  into 
the  surrounding  cellular  membrane,  and 
then  it  is  liable  to  be  confounded  with 
those  abscesses,  which  originate  in  this 
texture.  The  following  circumstances 
seem  to  warrant  this  opinion.  Thei'e  is 
no  bursa  more  liable  to  be  inflamed  ihan 
that,  between  the  patella  aud  the  skin, 
and  inflammation  of  it  not  unfrequently 
terminates  in  suppuration,  as  I  have  as- 
certained to  be  the  case,  both  by  the 
discharge  of  pu^,  when  the   tumor   has 


(      310      ) 

been  punctured,  and  by  dissection  aftci* 
deatli.  It  is  very  common  to  find  a 
large  abscess  on  the  anterior  part  of  the 
knee,  which  the  patient  describes  as  hav- 
ing commenced  over  the  centre  of  the 
patella,  in  the  situation  of  this  bursa.  The 
abscess  has  a  somewhat  peculiar  cha- 
racter. It  raises  the  skin  from  the  pa- 
tella, so  that  the  latter  cannot  be  felt, 
and  from  this  point,  as  from  a  centre, 
it  extends  itself  between  the  skin  and 
the  fascia,  equally  in  every  direction, 
covering  tbe  whole  of  the  anterior  part 
of  the  knee.  A  superficial  observer, 
judging  from  the  general  form  of  the 
tumor,  and  the  fluctuation  of  fluid,  with- 
out noticing  the  greater  redness  of  the  skin, 
and  the  circumstance  of  the  fluid  being 
over,  instead  of  under,  the  patella,  might 
mistake  the  case  for  one  of  inflammation 
of  the  synovial  membrane  of  tlie  joint  it- 
self. Such  an  abscess  must  be  supposed 
to  commence  either  in  the  bursa  above 


(     .311      ^ 

mentioned,  or  in  the  cellular  texturct 
The  original  situation  of  tlie  disease  cor- 
I'esponds  to  that  of  the  bursa:  there 
appears  to  be  no  reason  why  an  abscess 
of  the  cellular  texture  shoit*ld  occur  in  this 
precise  spot,  more  frequently  than  else- 
where: and  hence  it  is  reasonable  to 
conclude,  that  the  bursa  is  the  part  in 
which  the  abscess  begins.  It  is  not  im- 
probable that  many  otlier  abscesses  of 
the  extremities  may  have  a  similar  origin. 
The  tumor,  which  occurs  in  the  inside  of 
the  ball  of  the  great  toe,  and,  which  is  one 
of  those,  to  which  the  name  of  bunyon 
has  been  applied,  occasionally  suppurates; 
and  I  have  found  on  dissection,  that  this 
is  formed  by  an  inflammation  of  the  bursa, 
which  is  here  situated. 

It  frequently  happens,  after  the  inflam- 
mation has  entirely  subsided,  tliat  the 
disposition  to  secrete  a  preternatural 
quantity  of  fltiid  still  remains,  and  that 
a  dropsy  of  the  bursa  is  the  consequence. 


(  «12      ) 

in  like  manner  as  hydrocele  takes  place 
in  some  cases,  as  a  consequence  of  in- 
flammation of  the  tunica  vaginalis  of 
the  testicle.  Such  a  tumor  when  once 
formed,  may  continue  unaltered  for  many 
months,  or  even  for  years,  and  the  ma- 
jority of  ganglions  are  of  this  description. 

Sect.  II. 

On  the  Treatment. 

In  the  first  instance,  leeches  and  cold 
lotions,  and  afterward,  blisters  or  stimul- 
ating liniments  may  be  employed  with 
advantage;  and  in  particular  cases  these 
may  be  combined  with  such  constitu- 
tional remedies,  as  their  peculiar  circum- 
stances seem  to  indicate.  Under  this 
treatment  the  inflammation  of  the  bursa 
will  be  relieved  without  difficultv,  and  in 
the  early  stage  of  the  disease,  the  fluid, 
which  has  been  eff'used  will  become  ab- 
sorbed. 

But  where  the  disease  has  been  lone; 


(     313     ) 

established,  tlic  preternatural  secretion  of 
fluid  will  often  continue  after  the  inflam- 
mation has  entirely  subsided.  Under 
these  circumstances,  if  blisters  fail  in  pro- 
curing its  absorption,  friction  may  be 
employod,  and,  if  this  is  not  attended 
with  better  effects,  it  will  be  advisable 
tliat  the  fluid  should  be  evacuated  by 
puncture.  In  many  cases  the  loose  bo- 
dies which  have  been  described  in  the 
last  section,  are  found  in  tlie  cavity  of 
the  bursa,  and  these  extraneous  sub- 
stances may  in  themselves  be  sufficient 
to  keep  up  the  formation  of  fluid. 

I  have  observed,  where  the  puncture  of 
the  tumor  is  followed  by  suppuration, 
and  the  whole  cavity  of  the  bursa  is  thus 
converted  into  an  abscess,  that,  after  the 
suppuration  has  ceased,  no  further  col- 
lection of  fluid  in  general  takes  place, 
and  there  is  a  permanent  cure  of  the  dis- 
ease. Hence  I  have  sometimes  been 
induced,  after  using  the  lancet,  to  bring 

on  suppuration  by  artificial  means.     This 
11 


(    314    ; 

may  be  effected,  by  introducing  a  sdton 
or  tent  into  the  wound,  or  (wliicb  is 
more  simple,  and  in  all  respects  prefer- 
able) by  irritating  the  inner  surface  of  the 
bursa  with  the  blunt  end  of  a  probe. 
Even  where  the  bursa  forms  the  sheath 
of  one  or  more  tendons  this  method 
may  be  employed  with  safety,  though 
the  success  of  it  is  more  uncertain,  on 
account  of  the  greater  part  of  the  mem- 
brane being  beyond  the  reach  of  the 
operation. 

I  do  not  mean,  however,  to  affirm  that 
the  above  practice  should  be  extended  to 
all  eases  indiscriminately.  Inflammation 
and  suppuration  of  a  large  bursa  some' 
times  disturbs  the  constitution  in  so 
great  a  degree,  that  it  may  be  doubtful, 
whether  it  would  be  prudent,  in  this 
instance,  to  do  more  than  siiiply  punc- 
ture the  tumor,  keeping  the  patient  in 
a  state  of  perfect  quietude  afterwards, 
A  large  swelling,  formed  by  a  cyst  dis- 
tended with  scrum  only,  or  with  scrum 


(     815     ) 

and  masses  of  coagiilable  lympli  floating 
in  it,  occasionally  is  mot  with  over  the 
inferior  angle  of  the  scapula;  originating, 
as  I  apprehend,  in  the  large  bursa  mucosa 
which  is  interposed  at  this  part  between  the 
scapula  and  the  latissimus  dorsi  muscle.  I 
had  an  opportunity  of  seeing  a  tumor  of 
this  description,  which  had  attained  a 
magnitude  not  much  less  than  that  of  a 
man's  head.  I  understood  that  the  cyst 
was  afterwards  punctured  and  a  seton 
passed  through  its  cavity,  and  that  so 
much  disturbance  of  the  general  system 
ensued,  as  to  occasion  death.  I  have 
seen  another  case,  in  whicli  death  took 
place  in  a  short  time  after  such  a  tumor 
was  punctured,  but  here  the  patient  was 
otherwise  in  bad  health,  and  that  strict 
attention  was  not  paid  to  his  being  kept 
in  a  state  of  quietude  after  the  operation, 
which  the  circumstances  seem  to  have 
required.  I  shall  give  an  account  of  a 
more  fortunate  case  of  the  same  kind 
hereafter. 


(     316     )    . 

AVheii  tlie  coats  of  the  bursa  have  he- 
come  much  thickened,  I  am  not  aware 
that  there  is  any  method,  hj  which  they 
can  be  restored  to  their  natural  condition. 
If  the  diseased  bursa  be  situated  superfi- 
cially, it  may  be  removed  w  ith  as  mucJi 
facility  as  an  encysted  tumor.  I  have 
never  indeed  performed  this  operation 
myself,  nor  have  1  heard  of  it  being 
none  by  others,  except  on  the  bursa 
which  is  situated  between  the  patella  and 
the  skin;  but  there  can  be  no  doubt  that 
there  are  some  other  superficial  bursa?, 
to  which  the  operation  would  be  equally 
applicable  if  occasion  called  for  it.  On 
the  other  hand,  where  the  bursa  envelopes 
tendons,  or  where  it  is  deep-seated,  the 
operation  must  be  impracticable;  and 
where  the  bursa  communicates  with  the 
cavity  of  a  joint,  if  practicable,  it  must 
be  improper 

In  those  cases,  where  the  bursa  over 
the  patella  has  been  extirpated,  I  do  not 
know^  that  the  patient  has  afterwards  suf- 


(     317     ) 

fercd  any  inconvenience  from  the  want,  of 
it.  It  is  not  improbable  that  a  new  bursa 
may  ultimately  be  formed  to  supply  the 
place  of  that,  which  has  been  taken  away. 
A  synovial  membrane  is  of  simple  struc- 
ture. It  may  be  resolved  by  maceration 
into  cellular  texture,  and  instances  are 
not  wanting  of  new  synovial  membranes 
being  formed  where  none  before  existed. 
Such  is  the  case  in  an  artificial  joint  after 
an  united  fracture.  In  a  young  lady, 
who  has  attained  the  age  of  ten  or  twelve 
years,  labouring  under  the  inconvenience 
of  a  club  foot,  a  large  bursa  is  distinctly 
to  be  felt  on  that  part  of  the  instep  on 
which  she  treads. 

In  another  young  lady,  who  has  appar- 
ently recovered  of  a  caries  of  the  spine, 
attended  with  a  considerable  angular  cur- 
vature, a  bursa  appears  to  have  been 
formed  between  the  projecting  spinous 
process,  and  the  skin. 


(      S18      } 

Sect.  III. 

Cases  of  this  Disease. 

CASE  LV. 

Mary  Nevvnham,  twent\-two  years  of 
age,  was  admitted  into  St.  George's  Hos- 
pital, having  the  bursa  over  the  right  pa- 
tella enlarged  to  the  size  of  a  small  orange. 
It  contained  fluid,  and  the  membrane  of 
the  bursa  appeared  to  be  very  little  thick- 
ened. At  this  time  she  experienced  no 
pain,  and  there  was  no  inconvenience,  ex- 
cept what  arose  from  the  bulk  of  the 
tumor. 

Blisters  having  been  applied,  and  other 
methods  having  been  employed  with  a 
view  to  promote  the  absorption  of  fluid 
without  success,  I  made  a  puncture  with 
a  lancet,  and  more  than  an  ounce  of 
serous  fluid  escaped.  I  then  introduced 
the  blunt  end  of  a  probe,  and  irritated 
the  inner  surface  of  the  bursa:   in  consc- 


(     319     ) 

(fuence  of  Avliich,  on  the  following  day, 
there  was  some  degree  of  pain  and  swell- 
ing, with  a  slight  symptomatic  fever.  On 
the  fourth  day  after  the  operation,  on  re- 
moving the  dressings,  about  half  an  ounce 
of  pus  was  discharged.  The  suppura- 
tion continued,  but  the  quantity  of  pus 
daily  diminished,  and,  at  the  end  of  three 
weeks,  the  wound  was  healed,  and  the  tu- 
mor had  wholly  disappeared. 

CASE  LYI. 

Mrs.  T.,  between  twenty  and  thirty 
years  of  age,  in  the  middle  of  March, 
1811,  first  observed  a  tumor  situated 
over  the  inferior  angle  of  one  scapula, 
and  attended  with  a  trifling  degree  of 
pain  and  tenderness.  In  the  course  of  a 
week,  the  tumor  had  attained  its  greatest 
magnitude,  and  then  remained  station- 
ary. In  the  following  April,  when  she 
came  under  my  care,  the  tumor  was  of 
the  size  of  a  large  cocoa-nut;  of  an  oval 


(     820      ) 

sliape;  distinctly  circumscribed;  occupy- 
ing the  place  of  tlie  large  bursa  mucosa, 
which  is  situated  between  the  latissimus 
dorsi  muscle  and  the  inferior  angle  of  the 
scapula. 

On  the  22d  of  May,  the  tumor  being 
nearl}'  in  the  same  condition,  I  made  a 
puncture  with  an  abscess  lancet,  and 
about  a  pint  of  turbid  serum  was  evacu- 
ated, with  some  irregularly  shaped  masses 
of  coagulable  lymph  floating  in  it.  Ad- 
hesive plaster  was  placed  over  the  wound, 
and  secured  by  a  compress  and  bantlage^ 
and  she  was  desired  to  remain  perfectly 
quiet  in  bed.  The  wound  did  not  heal 
by  the  first  intention,  and,  on  removing 
the  dressinsjs  at  the  end  of  four  days,  a 
considerable  quantity  of  pus  escaped. 
The  discharge  of  pus  continued,  but  the 
quantity  daily  diminished,  no  untoward 
symptoms  took  place,  but  nearly  three 
months  elapsed  before  the  suppuration 
had  entirely  ceased,  and  the  wound  had 
healed.     At  this  time  there  were  no  re- 


(     321      ) 

mains  of  the  tumor,  and  she  was  in  all 
respects  well. 


CASE  LVII. 

A.  B.,  a  middle-aged  woman,  became  a 
patient  of  St.    George's   Hospital  imder 
Mr.  R.  Keate,  on  account  of  a  tumor  on 
the  back  part  of  the  wrist,  of  the  size  of  a 
double     walnut,     containing    fluid;    and 
which  had  been  the  consequence  of  in- 
flammation of  the  bursa  mucosa,  which  en- 
velopes the  extensor  tendons  of  the  fingers. 
At  the  time  of  her  coming  to  the  hospital 
the  inflammation  had  entirely  subsided, 
and  the  tumor  occasoned  no  inconveni- 
ence, except  what  might  be  attributed  to 
its  bulk.     After  having  employed  various 
local  remedies  without  any  reduction  of 
the  swelling,  a  puncture  was  made,  and  a 
considerable  quantity  of  serous  fluid  was 
evacuated.     In  a  short  time  however  the 
fluid  was  again  collected  in  as  largo  a  quan- 
42 


(      322      ") 

tity  as  before.  Afterwards  3Ii\  R.  Keate 
made  a  longitudinal  incision  in  the  skin 
over  the  tumor,  and  dissected  out  as 
much  as  possible  of  the  bursa,  leaving 
only  that  part  of  it  which  enveloped  the 
tendons.  The  wound  suppurated,  and 
healed  gradually^  and  at  first  it  was  sup- 
posed that  the  operation  had  produced 
a  cure.  But  in  a  few  weeks  after  the 
wound  had  cicatrized,  the  tumor  re- 
appeared, having  the  same  character  as 
before,  but  being  of  not  more  than  one 
half  of  its  former  size:  and  when  I  last 
saw  the  patient,  it  continued  in  the  same 
state. 

CASE  LVIII. 

Ruth  Target  was  admitted  into  St. 
George's  Hospital,  in  August,  1809,  on 
account  of  a  hard  and  apparently  solid 
tumor,  of  the  size  of  a  small  orange,  situ- 
ated between  the  patella  and  the  skin,  and 
perfectly  moveable  on  the  parts  below. 


(     323     ) 

Having  made  a  longitudinal  incision 
of  the  integuments  I  removed  the  tumor 
with  perfect  facility.  A  slight  degree  of 
symptomatic  fever  followed  the  oper- 
ation, which  however  speedily  subsided, 
and  at  the  end  of  a  month,  she  was 
discharged  as  cured,  sufl'ering  no  incon- 
venience except  a  very  trifling  sense  of 
stiffness,  when  she  walked. 

On  examining  the  tumor,  after  its  re- 
moval, it  was  found  to  be  formed  by  the 
bursa,  which  is  situated  over  the  patella; 
the  parietes  of  which  had  become  more 
than  half  an  inch  in  thickness,  and  of  a 
ligamentous  texture;  while  the  interior 
retained  its  natural  cellular  structure,  and 
was  filled  with  a  serous  fluid. 

I  have  lately  performed  a  similar  oper- 
ation on  another  patient.  After  the 
wound  was  healed,  there  was  at  first 
considerable  stiftness  of  the  knee,  in  con- 
sequence of  the  cicatrix  having  formed  a 


(     324     ) 

close  attachment  to  tUe  anterior  surface 
of  the  patella;  but  at  this  time,  three 
months  from  the  day  of  the  operation, 
the  skin  has  become  so  moveable  on  the 
parts  below,  tliat  there  is  every  reason  to 
believe  that  a  new  bursa  may  be  gene- 
rated to  supply  the  place  of  the  old  one. 


4^ 


Tt.j.t 


Fuf.2. 


/ 


^ 


V 


Fuj.J. 


natf 


f 


M:^/i!rj-i>n  Sc. 


EXPLANATION  OF  THE  PLATEB. 


Plate  I. 

Fig.  1.  A  part  of  the  synovial  mem- 
brane of  tbe  Einee  in  a  state  of  inflam- 
mation, and  lined  with  coagnlable  Ijmph. 
This  is  introduced,  piincipally,  with  a 
view  to  the  appearances  being  contrasted 
with  those  in 

Fig.  2.  and  Jig.  3.  which  represent  the 
cut  siiriaces  o(*  two  small  portions  of  a 
synovial  membrane,  which  had  nnder- 
gone  the  peculiar  morbid  alteration  of 
structure,  which  has  been  described  in 
the  third  chapter. 

Plate  II. 

A  knee-joint,  the  synovial  membrane 
of  which  had  undergone  the  same  alter- 
ation of  structure.  In  order  to  make  the 
drawing,   the  joint  was  cut   into   at  its 


(      326      ) 

upper  and  lateral  parts,  and  the  anterior 
portion  of  the  synovial  membrane  was 
turned  downwards,  so  as  to  expose  the  in- 
ternal surface. 

A,  The  cartilage  covering  the  condyles 
of  the  femur. 

B,  The  cartilage  lining  the  patella. 

C  C  C,  The  inner  surface  of  the  dis- 
eased synovial  membrane. 

D  D,  The  cut  surfaces  of  the  skin  and 
adipose  substance. 

Plate  III. 

The  joint  of  the  hip,  affected  with  ul- 
ceration of  the  cartilage,  from  a  child 
seven  years  old.  The  greater  part  of  the 
synovial  membrane  and  capsular  liga- 
ment have  been  removed,  so  as  to  ex- 
pose more  completely  the  interior  of  the 
joint.  The  round  ligament,  (which  was 
partly  destroyed  by  ulceratioa,  where  it 
was  connected  to  the  acetabulum)  has 
been  torn  through,  so  as  to  allow  of  the 
head  of  the  femur  being  dislocated. 


Ila/. 


(     327     ) 

A,  A  portion  of  the  os  innominatum. 

B,  The  head  of  the  femur. 

C,  The  acetahulum. 

D,  The  inner  surface  of  the  synovial 
membrane  in  a  natural  state. 

E,  Portions  of  the  hone  of  the  ace- 
tabulum exposed,  inconsequence  of  the 
cartilage  having  been  ulcerated. 

F,  A  portion  of  the  cartilage  covering 
the  head  of  the  femur  converted  into  a 
fibrous  substance. 

G,  The  great  trochanter. 

Plate  IV. 

The  knee-joint  affected  with  ulceration 
of  the  cartilages.  The  interior  of  it 
is  exposed  in  the  same  manner  as  in 
Plate  II. 

A,  The  femur. 

B,  The  tibia. 

C,  The  inner  surface  of  the  patella, 
the  cartilage  of  which  has  been  in  great 
measure  destroyed  by  ulceration. 

J3,     The  surface  of  the  external  con- 


(     328     ) 

dyle  of  the  femur,  the  cartilage  of  >yhich 
is  partly  ulcerated  also. 

E,  The  inner  surface  of  the  synovial 
membrane  in  a  natural  state. 

F,  The  inner  Condyle  of  the  femur 
covered  by  a  substance  resembling  that 
of  adhesions. 

Plate  V. 

A  portion  of  the  carious  spine  of  a 
child,  to  shew  the  disease  originating  in 
the  intervertehral  cartilages. 

A,  The  seat  of  the  curvature,  where 
the  bodies  of  two  vertebrse  have  been 
destroyed. 

B,  C,  The  spaces  formed  by  the  ab- 
sorption of  the  intervertebral  cartilages, 
while  the  bones  have  been  left  entire. 

Plate  VI. 

The    preparation,    from    which    this 

drawing   was    taken,    is    in  Mr.   Ileavi- 

side's  collection.     The  history  of  the  case 

is  not  known,  but  the   appearances  arc 


P/(if^e,  3. 


m 


f^"?^- 


'tV<' 


7///'^"<•  o\ 


r:?,  '^S    -, --  . 


-    JM 


0 


:'""!!# 


(      329      ) 

precisely  similar  to  those,  wliich  I  liave 
observed  in  other  cases,  in  whicli  caries 
of  the  spine  has  been  induced  by  the 
pressure  of  a  tumor  situated  externally 
to  it.  Tliis  figure  is  introduced,  chiefly, 
for  the  purpose  of  it  being  contrasted  with 
the  figure  in  the  last  plate. 

A,  C,  The  bodies  of  the  vertebrse  de~ 
»lroyed  to  a  considerable  extent,  while 
the  intervertebral  cartilage  between  them 
B.  remains  entire. 


For  the  greater  number  of  the  draw- 
ings from  which  these  plates  were  taken, 
I  am  indebted  to  the  kindness  of  Mr. 
Howship  and  Mr.  Gaskoin,  whose  ana- 
tomical knowledge  have  enabled  them  to 
express  the  various  morbid  appearances 
with  peculiar  accuracy. 

THE  END, 


1 


^Bm>^;.lA«lM»t«P 


COLUMBIA  UNIVERSITY   LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 


=^===== 

DATE  BORROWED                 DATE  DUE 

DATE  BORROWED 

DATE  DUE 

1 

1 

1 

1 

C28(946)M100 

3 

RD686 

(Brodie 

Pathol( 
Ivations 
Ijoints 


APR 


2 


B78^g^ 
cop.  2 

obser- 
the 


^y 


'9' 


-  mm . 


